Miscellaneous ll

  1. 1
    • 1. How does Succinylcholine produce its actions at muscle end plate?
    • a. Blocking calcium channels
    • b. Blocking sodium channels
    • c. Opening calcium channels
    • d. Opening sodium channels

    • Ans: d
    • Ref: Miller’s anesthesia, 8th edition, page 435
    • Suxamethonium (Succinylcholine) is a short acting depolarizing neuromuscular blocking agent which acts by opening the sodium channels at the muscle end plate.

    • 2. Anesthetic agent with minimal hemodynamic alteration is
    • a. Halothane
    • b. Sevoflurane
    • c. Isoflurane
    • d. Enflurane

    • Ans: b
    • Ref: Morgan & Mikhail’s Clinical Anesthesiology, 3rd Edition, Page No: 145-147
    • • Sevoflurane is agent of choice in pediatric procedures

    • • Excellent choice for smooth & rapid inhalataional induction in pediatric population because
    • o Sweet odour
    • o Rapid increase in alveolar anesthetic concentration i.e. rapid onset of action

    • Minimal effect on CVS with minimal hemodynamic alteration

    • 3. A 25 year old gentleman with head injury with extradural hematoma is planned for surgery. Which of the following is contraindicated in that surgery
    • a. Ketamine
    • b. Halothane
    • c. Propofol
    • d. Thiopentone

    • Ans: a
    • Ref: Miller’s Anesthesia, 7th Edition, Page No: 744-46
    • Ketamine increases cerebral blood flow, metabolism, oxygen consumption and increases the intra cranial tension hence is contraindicated in head injury.

    • 4. Not done during mouth-to-mouth ventilation technique:
    • a. Put the mouth completely over the patient’s mouth
    • b. Keep the patient’s nostrils clear to assist spontaneous expiration
    • c. After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
    • d. Give each breath for approximately 1 second with enough force to make the patient’s chest rise

    • Ans: b
    • To perform the mouth-to-mouth technique, the provider does the following:
    • - Pinch the patient’s nostrils closed to assist with an airtight seal
    • - Put the mouth completely over the patient’s mouth
    • - After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
    • - Give each breath for approximately 1 second with enough force to make the patient’s chest rise
    • - Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion
    • - After giving the 2 breaths, resume the CPR cycle
  2. 2
    PSYCHIATRY QUIZ

    • 1. What is the commonest symptom of narcolepsy?
    • a. Cataplexy
    • b. Hypnagogic hallucination
    • c. Sleep attacks
    • d. Sleep paralysis

    • Ans: c
    • Ref: Niraj Ahuja Psychiatry 7th Edition, Page No: 138 -139
    • • Narcolepsy is a disorder characterized by excessive day time sleepiness, often disturbed night-time sleep and disturbances in the REM sleep. The hallmark of this disorder is REM latency, ie, decreased latent period before the first REM period occurs. Normal REM latency is 90 – 100 minutes.
    • • The classic tetrad of symptoms of narcolepsy are:
    • o Sleep attacks (most common symptom)
    • o Cataplexy
    • o Hypnagogic hallucination (hallucination occurring while falling asleep)
    • o Sleep paralysis (least common symptom)

    • 2. A patients feels he is being followed and they are planning to do him harm. This is called:
    • a. Persecutory Delusion
    • b. Psychosis
    • c. Mania
    • d. Phobia

    • Ans: a
    • Ref: Niraj Ahuja Psychiatry 7th Edition, Page No: 56
    • The commonly seen delusions in schizophrenia include:
    • • Delusions of persecution (being persecuted against, e.g. ‘people are against me’).
    • • Delusions of reference (being referred to by others; e.g. ‘people are talking about me’).
    • • Delusions of grandeur (exaggerated self-importance; e.g. ‘I am God almighty’).
    • • Delusions of control (being controlled by an external force, known or unknown; e.g. ‘My neighbor is controlling me”).
    • • Somatic (or hypochondriacal) delusions (e.g. ‘there are insects crawling in my scalp’).

    • 3. A 35-year-old female presents to her physician at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping. Despite a lack of sleep, she is "full of energy" during the day at her teaching job, which she believes is "beneath [her], anyway." She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. Which of the following is the best initial treatment?
    • a. Valproate
    • b. Valproate and venlafaxine
    • c. Valproate and olanzapine
    • d. Haloperidol

    • Ans: c
    • This patient with decreased need for sleep, ideas of grandiosity, and pressured speech is showing symptoms of an acute manic episode. First line management of an acute manic episode includes assessing the patient for suicidal idealization and treatment with a mood stabilizer (valproate) and an antipsychotic (olanzapine).
    • The patient meets the diagnostic criteria for Bipolar I (an episode of mania with or without episodes of depression), where mania is defined by having 3 of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-oriented activity, psychomotor agitation, and hedonism. Acute episodes are managed with a mood stabilizer (lithium or valproate) and an antipsychotic: olanzapine or quetiapine.

    • 4. Early onset and bad prognosis is seen in:
    • a. Catatonic schizophrenia
    • b. Hebephrenic schizophrenia
    • c. Paranoid schizophrenia
    • d. Undifferentiated schizophrenia

    • Ans: b
    • Ref: Niraj Ahuja Psychiatry 7th Edition, Page No: 58
    • Disorganised (or Hebephrenic) Schizophrenia
    • Disorganised schizophrenia is characterized by the following features, in addition to the general guidelines of schizophrenia described earlier:
    • • Marked thought disorder, incoherence and severe loosening of associations. Delusions and hallucinations are fragmentary and changeable.
    • • Emotional disturbances (inappropriate affect, blunted affect, or senseless giggling), mannerisms, ‘ mirror-gazing’ (for long periods of time), disinhibited behaviour, poor self-care and hygiene, markedly impaired social and occupational functioning, extreme social withdrawal and other oddities of behaviour.
    • ICD-10 recommends a period of 2 or 3 months of continuous observation for a confident diagnosis of disorganised (or hebephrenic) schizophrenia to be made.
    • • The onset is insidious, usually in the early 2nd decade. The course is progressive and downhill. The recovery from the episode is classically poor. Severe deterioration, without any significant remissions, usually occurs over time.
    • • Hebephrenic schizophrenia has one of the worst prognoses among the various subtypes of schizophrenia.

    • Catatonic: Best prognosis (best response to ECT), late onset
    • Paranoid: Most common form, late onset
    • Hebephrenic: Worst prognosis in early onset
    • Simple: Least common, early onset, worse prognosis
  3. 3
    • 1. In resource limited countries, High-Throughput PCR Diagnosis of COVID-19 can be done using which of the following method?
    • a. Limited sample collection
    • b. Sample pooling
    • c. Skipping few steps of PCR
    • d. Using same reagent for multiple sample after sterilization

    • Ans: b
    • - Diagnostic assays can be scaled up by the method of High-Throughput qPCR via sample pooling.
    • - Pooling, the action of combining multiple samples into one tube, is most effective when the chance of positive detection of the target, SARS-CoV-2 RNA, is low.
    • - In such cases, large groups of samples can be conclusively classified as negative with a single test, with no need to individually test every sample.

    • 2. Pachymeninx means?
    • a. Dura mater
    • b. Dura mater + Arachnoid mater
    • c. Arachnoid mater + Pia mater
    • d. Pia mater

    • Ans: a
    • Ref: Gray’s Anatomy, 41st edition, page 432, 440
    • • Three concentric membranes, the meninges, envelop the brain and spinal cord. They provide support and protection for the delicate tissues they surround. The individual layers, in order from outside to inside, are the dura mater (pachymeninx), arachnoid mater and pia mater.
    • • The dura is an opaque, tough, fibrous coat that incompletely divides the cranial cavity into compartments and accommodates the dural venous sinuses. The arachnoid is much thinner than the dura and is mostly translucent. It loosely surrounds the brain, cranial nerves and vessels, spanning fissures and sulci. The pia mater is a transparent, microscopically thin membrane that follows the contours of the brain and is closely adherent to its surface.
    • • The arachnoid mater and the pia mater together are sometimes referred to as the leptomeninges.

    • 3. Tension band wiring is being used to fix a bone fractured in a fall from height. Likely bone is:
    • a. Ulna
    • b. Patella
    • c. Clavicle
    • d. Radius

    • Ans: b
    • Ref: Ebnezar Orthopedics 4th Edition, Page No: 741
    • Tension band wiring is for olecranon, patella and medial malleolus.

    • 4. All of the following clinical signs are observed in choledocholithiasis except:
    • a. Biliary colic
    • b. Dyspepsia
    • c. Flatulence
    • d. Murphy’s sign

    • Ans: d
    • Ref: Sabiston Surgery 20th Edition, Page No: 1493
    • • Murphy’s sign is not seen in choledocholithiasis.
    • • Murphy’s sign is positive if inflammation of the peritoneum occurs: tenderness and the presence of Murphy’s sign helps distinguish acute cholecystitis from biliary colic, in which the inflammatory process does not occur.

    • How to elicit Murphy’s sign?
    • • Ask patient to exhale
    • • Examiner places hand below costal margin on the right side at the mid-clavicular line
    • • The patient is instructed to inspire

    Positive Murphy’s sign: The patient stops breathing in and winces with a ‘catch’ in breath (Due to the inflamed gallbladder being palpated as it descends on inspiration)

    Murphy’s triad (Pain in the right iliac fossa, vomiting, fever) is associated with acute appendicitis.
  4. 4
    • 1. Real-time PCR (qPCR) provides advantages of:
    • a. Automation
    • b. Higher-throughput
    • c. More reliable instrumentation
    • d. All of the above

    • Ans: d
    • Reverse transcription polymerase chain reaction
    •  Polymerase chain reaction (PCR) is a process that amplifies (replicates) a small, well-defined segment of DNA many hundreds of thousands of times, creating enough of it for analysis. Test samples are treated with certain chemicals that allow DNA to be extracted. Reverse transcription converts RNA into DNA.
    •  Reverse transcription polymerase chain reaction (RT-PCR) first uses reverse transcription to obtain DNA, followed by PCR to amplify that DNA, creating enough to be analyzed. RT-PCR can thereby detect SARS-CoV-2, which contains only RNA. The RT-PCR process generally requires a few hours.
    •  Real-time PCR (qPCR) provides advantages including automation, higher-throughput and more reliable instrumentation. It has become the preferred method.

    • 2. Which variant of AML is associated with Auer rods?
    • a. Acute myeloblastic leukemia
    • b. Acute promyelocytic leukemia
    • c. Acute myelomonocytic leukemia
    • d. Acute monocytic leukemia

    • Ans: b
    • Ref: Robbins Basic Pathology, 10th edition, page 479
    • • Auer rods, distinctive red-staining rodlike structures, may be present in myeloblasts or more differentiated cells; they are particularly numerous in acute promyelocytic leukemia.
    • • Auer rods are specific for neoplastic myeloblasts and thus are a helpful diagnostic clue when present.
    • • In other subtypes of Acute Myeloid Leukemia, monoblasts, erythroblasts, or megakaryoblasts predominate.

    • 3. Garden classification is used for which fracture?
    • a. Ankle
    • b. Hip
    • c. Knee
    • d. Shoulder

    • Ans: b
    • Ref: Apley & Solomon’s System of Orthopaedics & Trauma, 10th edition, page 885
    • • The most commonly used classification in Intra-Capsular Hip Fracture is the Garden classification, which is based on the amount of displacement apparent on X-rays of the hip.

    • 4. Mitral stenosis is associated with
    • a. Right ventricular hypertrophy
    • b. Left ventricular hypertrophy
    • c. Left axis deviation
    • d. QRS complex

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1814-1815
    • Mitral stenosis:
    • Rheumatic fever is the leading cause of mitral stenosis
    • ECG findings in mitral stenosis are:
    • - P wave usually suggests LA enlargement
    • - Right atrial (RA) enlargement occurs
    • - With severe pulmonary hypertension, right axis deviation and RV hypertrophy are often present
    • Chest X-Ray findings:
    • - Earliest changes are straightening of the upper left border of the cardiac silhouette,
    • - Posterior displacement of the esophagus by an enlarged LA.
    • - Kerley B lines are fine, dense, opaque, horizontal lines that are most prominent in the lower and mid-lung fields

    • 5. Novus actus interveniens is:
    • a. Contributory negligence
    • b. Therapeutic misadventure
    • c. Facts speaks for itself
    • d. Breaking of chain

    • Ans: d
    • Ref: Gautam Biswas Forensic Medicine, 3rdEdition, Page No: 19-20
    • Novus Actus Interveniens
    • (Unrelated Intervening Action)
    • • If a doctor is negligent, which results in deviation from the logical sequence of events, then the responsibility for the subsequent disability or death may pass from original incident to the negligent act of the doctor.
    • • A novusactus is something which `breaks the chain of causation’.
    • • For a plea of novusactusinterveniens, an element of negligence is essential.
    • • It usually applies to cases of accidents and assaults, like leaving a swab or instrument in the abdomen after laparotomy.
    • • Plea is rarely accepted by the courts.
    • Doctrine of Res ipsa loquitur
    • • Generally, professional negligence of a doctor must be proved in the court by expert evidence of another physician.
    • • The patient need not prove negligence in case where the rule of res ipsa loquitur applies, which means ‘the thing or fact speaks for itself.’
  5. 5
    • 1. Shape of Helicobacter pylori is:
    • a. Comma
    • b. Pipe
    • c. Amoeboid
    • d. Meat ball

    • Ans: a
    • Helicobacter pylori
    • Gram-negative, spiral-shaped (comma-shaped), catalase-positive, urease-positive, oxidase-positive rod with motile flagella.

    • 2. Triple screen does not include:
    • a. AFP
    • b. Estriol
    • c. Beta-hCG
    • d. Inhibin A

    • Ans: d
    • Triple screen measures serum levels of AFP, estriol, and beta-hCG
    • A test of levels of dimeric inhibin A (DIA) is sometimes added to the other three tests, under the name "quadruple test.

    • 3. Niacin is:
    • a. B1
    • b. B2
    • c. B3
    • d. B5

    • Ans: c
    • • B1 (thiamine: TPP)
    • • B2 (riboflavin: FAD, FMN)
    • • B3 (niacin: NAD+)
    • • B5 (pantothenic acid: CoA)
    • • B6 (pyridoxine: PLP)
    • • B7 (biotin)
    • • B9 (folate)
    • • B12 (cobalamin)
    • • C (ascorbic acid)

    • 4. Psammoma bodies are seen in:
    • a. Papillary carcinoma of thyroid
    • b. Malignant Mesothelioma
    • c. Meningioma
    • d. All of the above

    • Ans: d
    • Psammoma bodies seen in:
    • • Papillary carcinoma of thyroid
    • • Somatostatinoma
    • • Meningioma
    • • Malignant Mesothelioma
    • • Ovarian serous papillary cystadenocarcinoma
    • • Prolactinoma

    • 5. Stating that there is an effect or difference when none exists is:
    • a. Type I error
    • b. Type II error
    • c. Type III error
    • d. Type IV error

    • Ans: a
    • • Type I error (α ) Stating that there is an effect or difference when none exists (null hypothesis incorrectly rejected in favor of alternative hypothesis).
    • • Type II error (β ) Stating that there is not an effect or difference when one exists (null hypothesis is not rejected when it is in fact false).

    • 6. Which of the following is not seronegative spondyloarthritis?
    • a. Psoriatic arthritis
    • b. Ankylosing spondylitis
    • c. Inflammatory bowel disease
    • d. Rheumatoid arthritis

    • Ans: d
    • Seronegative spondyloarthritis
    • Strong association with HLA-B27 (MHC class I serotype).
    • Subtypes (PAIR) share variable occurrence of inflammatory back pain (associated with morning stiffness, improves with exercise), peripheral arthritis, enthesitis (inflamed insertion sites of tendons, eg, Achilles), dactylitis (“sausage fingers”), uveitis.
    • • Psoriatic arthritis
    • • Ankylosing spondylitis
    • • Inflammatory bowel disease
    • • Reactive arthritis

    • 7. Sudden, jerky, purposeless movement is
    • a. Chorea
    • b. Dystonia
    • c. Athetosis
    • d. Asterixis

    • Ans: a
    • • Akathisia: Restlessness and intense urge to move
    • • Chorea: Sudden, jerky, purposeless movements
    • • Dystonia: Sustained, involuntary muscle contractions
    • • Athetosis: Slow, snake-like, writhing movements; especially seen in the fingers
    • • Asterixis: Extension of wrists causes “flapping” motion
  6. 6
    • 1. Most common method of contraception is Nepal is:
    • a. Depo
    • b. Condom
    • c. Implant
    • d. Female sterilization

    • Ans: a
    • Ref: Annual Report; Department of Health Services; 2074/75 (2017/18)
    • Depo (37%) occupies the greatest part of the contraceptive method mix for all method new acceptors, followed by condom (27%), implant (19%), IUCD (4%), female sterilization (ML 3%) and lastly male sterilization (NSV 1%) in 2074/75.

    • 2. Casal’s necklace is seen in
    • a. Niacin deficiency
    • b. Rickets
    • c. Vit A deficiency
    • d. B12 deficiency

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 96e-4
    • • Niacin deficiency causes pellagra, which is found mostly among people eating corn-based diets in parts of China, Africa, and India.
    • • Pellagra in North America is found mainly among alcoholics; among patients with congenital defects of intestinal and kidney absorption of tryptophan (Hartnup disease); and among patients with carcinoid syndrome, in which there is increased conversion of tryptophan to serotonin.
    • • The antituberculosis drug isoniazid is a structural analog of niacin and can precipitate pellagra.
    • • In the setting of famine or population displacement, pellagra results from the absolute lack of niacin but also from the deficiency of micronutrients required for the conversion of tryptophan to niacin (e.g., iron, riboflavin, and pyridoxine).
    • • The early symptoms of pellagra include loss of appetite, generalized weakness and irritability, abdominal pain, and vomiting. Bright red glossitis then ensues and is followed by a characteristic skin rash that is pigmented and scaling, particularly in skin areas exposed to sunlight. This rash is known as Casal’s necklace because it forms a ring around the neck; it is seen in advanced cases. Vaginitis and esophagitis also may occur. Diarrhea (due in part to proctitis and in part to malabsorption), depression, seizures, and dementia are also part of the pellagra syndrome. The primary manifestations of this syndrome are sometimes referred to as “the four D’s”: dermatitis, diarrhea, and dementia leading to death.

    • 3. Which of the following is true for transudative pleural effusions?
    • a. Pleural fluid protein / serum protein >0.5
    • b. Pleural fluid LDH / serum LDH >0.6
    • c. Pleural fluid LDH > two-thirds normal upper limit for serum
    • d. None of the above

    • Ans: d
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1716
    • Light’s criteria - Out of the following, exudative pleural effusions meet at least one, whereas transudative pleural effusions meet none. Pleural fluid protein/serum protein >0.5, pleural fluid LDH/ serum LDH >0.6 and pleural fluid LDH more than two-thirds normal upper limit for serum. Still, if clinically transudative effusion is strongly suspected, difference between albumin levels in serum and pleural fluid is estimated. If this difference is >3.1 g/dL, pleural effusion is transudative.

    • 4. A 32-year-old male janitor complains of a swollen face during the past week. A CT scan reveals an expanding hematoma in the superior mediastinum. Mediastinal tamponade is most likely to manifest as which of the following?
    • a. Hypertension
    • b. Increased pulse pressure during inspiration
    • c. Paresis of the right arm
    • d. Venous congestion in the upper extremity

    • Ans: d
    • In mediastinal tamponade, hypotension, dyspnea, cyanosis, and a decrease in pulse pressure will be evident. During inspiration, the pulse pressure is further impeded to cause obstruction to transmitted ACV waves in the neck; in congestive cardiac failure, the ACV waves recorded in the neck are more prominent. Paresis of the arm is unlikely to occur, because the lower part of the brachial plexus (T1) passes along the inner border of the first rib to reach the neck.
  7. 7
    • 1. What is Whitfield’s ointment composed of?
    • a. Benzoic acid and kojic acid
    • b. Benzoic acid and salicylic acid
    • c. Retinoic acid and salicylic acid
    • d. Salicylic acid and undeclenic acid

    • Ans: b
    • Ref: Rook’s Textbook of Dermatology, 9th edition, page 18.12
    • Whitfield’s ointment, a combination of 6% benzoic acid and 3%salicylic acid in a petrolatum base, is effective in the treatment of superficial dermatophyte infections.

    • 2. Which is not a common site of occurrence of lesions of atopic dermatitis in an infant?
    • a. Face
    • b. Flexor surfaces
    • c. Extensor surfaces
    • d. Scalp

    • Ans: b
    • Ref: Fitzpatrick’s Dermatology, 9th edition, page 364 – 365
    • • The distribution of eczematous lesions varies according to the patient’s age and disease activity.
    • • During infancy, the Atopic dermatitis is generally more acute and primarily involves the face, the scalp, and the extensor surfaces of the extremities.
    • • In older children and in those who have long-standing skin disease, the patient develops the chronic form of AD with lichenification and localization of the rash to the flexural folds of the extremities.
    • • AD may subside as the patient grows older, leaving an adult with skin that is prone to itching and inflammation when exposed to exogenous irritants.

    • 3. A 36-year-old woman comes to the clinic for rashes on her elbows. The patient reports that the lesions have been present for the past 4 months and have been intermittently itchy. She is bothered by them as she works in luxury retail. A physical examination demonstrates red-purple papules/plaques with silvery scales bilaterally on the elbows. What other conditions can you expect to see in this patient?
    • a. Allergic rhinitis
    • b. Dactylitis
    • c. Gastrointestinal malignancy
    • d. Hepatitis C

    • Ans: b
    • This patient has psoriasis (e.g., red-purple papules/plaques with silvery scales on bilateral elbows). The condition is associated with nail pitting and psoriatic arthritis, which can present with joint pain and dactylitis.
    • Psoriasis is a common chronic inflammatory skin disease that is characterized by well-demarcated, erythematous plaques with silvery scale. The plaques are usually symmetrically distributed with the most common locations being the scalp, extensor surfaces (elbows, knees), and gluteal clefts. The lesions may be pruritic or painful at times. Histopathological findings include Munro microabscesses and acanthosis with parakeratotic scaling. The condition is associated with psoriatic arthritis, which is one of the seronegative spondyloarthropathies.

    • 4. A lady presents with an itchy lesion over trunk which is erythematous, annular, periphery is elevated with few papules and central clearing and is extending peripherally. The most likely diagnosis is:
    • a. Tinea versicolor
    • b. Tinea corporis
    • c. Granuloma annulare
    • d. Lichen planus

    • Ans: b
    • Ref: Dermatology, Neena Khanna, 4th edition, Page No: 284, 291, 56, 383
    • Tinea: A typical lesion
    • • Margin is active with papules, vesicles, and pustules and the center is clear (if of short duration)
    • • shows hyperpigmentation/lichenification/nodules (in chronic cases)
    • • typical annular plaque with activity at the edge and relative clearing in the center
    • • edge of the lesion showing papulovesiculation and scaling

    • Pityriasis (Tinea) versicolor:
    • • Perifollicular, hypopigmented macules with branny scales.
    • • Sometimes lesions are hyperpigmented.
    • • Accentuation of scaling on scratching

    • Granuloma Annulare
    • • Association of diabetes and granuloma annulare is controversial.
    • • Skin colored or erythematous dermal papules arranged in an annular pattern
    • • Most frequently seen on pressure points, like knuckles and dorsal aspect of hands.

    Lichen planus: Pruritic, Polygonal, Purple (but violaceous is the term to use!), Plane (flat topped), Papules with Wickham’s striae on surface.
  8. 8
    • 1. A young patient undergoes CT of the paranasal sinuses. The main finding is an enhancing nasal mass with widening of the left pterygopalatine fissure. What is the most likely diagnosis?
    • a. Adenoid cystic carcinoma
    • b. Angiofibroma
    • c. Angiosarcoma
    • d. Inverting papilloma

    • Ans: b
    • Ref: Grainger and Allison's Radiology, 5th Edition, Page No: 1419, 1421
    • A nasal mass with widening of the pterygopalatine fissure is pathognomonic of juvenile angiofibroma.

    • 2. Tear-drop bladder is seen in:
    • a. Pelvic abscess
    • b. Pelvic lipomatosis
    • c. Bladder rupture
    • d. All of the above

    • Ans: d
    • Pear-shaped (or teardrop-shaped) bladder is one whose normal round or ovoid shape has been extrinsically compressed to resemble a pear. The pear may be inverted or upright, depending on how the excess pelvic tissue compresses the bladder.
    • Causes of a pear-shaped bladder include:
    • • Pelvic fluid/abscess
    • • Pelvic lipomatosis
    • • Vascular dilatation
    • • Bilateral iliac artery aneurysms; upright pear-shape
    • • Inferior vena cava (IVC) occlusion

    • 3. Bulging fissures in lungs in seen in:
    • a. Klebsiella pneumonia
    • b. Staphylococcal pneumonia
    • c. Pulmonary edema
    • d. Pneumoconiosis

    • Ans: a
    • Ref: Bulging fissure sign (lobar consolidation) by Assoc Prof Craig Hacking and Assoc Prof Frank Gaillard et al in Radiopedia.
    • The bulging fissure sign refers to lobar consolidation where the affected portion of the lung is expanded causing displacement of the adjacent fissure. Any type of pneumonia or space-occupying process can lead to bulging (sagging) fissure sign. Classically, it has been described in right upper lobe (RUL) consolidation secondary to Klebsiella pneumonia. It is now rarely seen due to prompt antibiotic therapy for suspected pneumonia.

    • 4. The frequency of the sound waves used in medical ultrasound is in the range of:
    • a. kHz
    • b. MHz
    • c. mHz
    • d. PHz

    • Ans: b
    • Ref: Ultrasound (introduction) by Dr Matt A. Morgan in Radiopedia.
    • Ultrasound relies on properties of acoustic physics (compression/rarefaction, reflection, impedance, etc.) to localize and characterize different tissue types. The frequency of the sound waves used in medical ultrasound is in the range of millions of cycles per second (megahertz, MHz). In contrast, the upper range of audible frequencies for human is around 20 thousand cycles per second (20 kHz).
  9. 9
    • 1. Most common secondary changes in fibroid is:
    • a. Hyaline degeneration
    • b. Necrosis
    • c. Infection
    • d. Sarcomatous change

    • Ans: a
    • Ref: DC Dutta Textbook of Gynecology including Contraception; 6th Edition, Page No: 275
    • Secondary changes in fibroid
    • • Hyaline degenerations
    • • Atrophy
    • • Necrosis
    • ��� Infection
    • • Vascular changes
    • • Sarcomatous change
    • Hyaline degeneration is the most common (65%) type of degeneration affecting all sizes of fibroids except the tiny one. It is common especially in tumors having more connective tissues. The central part of the tumor which is least vascular is the common site. The feel becomes soft elastic in contrast to firm feel of the tumor.
    • Red degeneration (carneous degeneration) occurs in a large fibroid mainly during second half of pregnancy and puerperium. Partial recovery is possible and as such called necrobiosis. The cause is not known but is probably vascular in origin. Infection does not play any part.

    • 2. Maximum risk to fetus occurs when maternal infection with rubella occurs during which of the following time:
    • a. 6-12 wks
    • b. 12-28 wks
    • c. 14-20 wks
    • d. 20-24 wks

    • Ans: a
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1549
    • The most important risk factor for severe congenital defects is the stage of gestation at the time of infection. Maternal infection during the 1st 8 wk of gestation results in the most severe and widespread defects. The risk for congenital defects has been estimated at 90% for maternal infection before 11 wk of gestation, 33% at 11-12 wk, 11% at 13-14 wk, and 24% at 15-16 wk. Defects occurring after 16 wk of gestation are uncommon, even if fetal infection occurs.

    • 3. Which of these is the best study to evaluate effect and outcome?
    • a. Clinical trial
    • b. Cohort
    • c. Case control study
    • d. Cross sectional study

    • Ans: b
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 75
    • COHORT STUDY:
    • In contrast to case control studies which proceed from "effect to cause", the basic approach in cohort studies is to work from "cause to effect"
    • That is, in a case control study, exposure and disease have already occurred when the study is initiated. In a cohort study, the exposure has occurred, but the disease has not.
    • A well-designed cohort study is considered the most reliable means of showing an association between a suspected risk factor and subsequent disease because it eliminates many of the problems of the case control study and approximates the experimental model of the physical sciences.

    • 4. Erythrasma is caused by:
    • a. Corynebacterium minutissimum
    • b. Corynebacterium diphtheriae
    • c. Corynebacterium vaginalis
    • d. Corynebacterium ulcerans

    • Ans: a
    • Ref: Dermatology, Neena Khanna, 4th edition, Page No: 242, 243
    • Erythrasma
    •  Causative agent: Corynebacterium minutissimum.
    •  Predisposing factors: Warm humid climate.
    • Clinical features
    •  Asymptomatic, well-defined, irregular, scaly, uniformly pink but more frequently brown macules. Creasing or wrinkling of lesions is characteristic.
    •  Depth of the flexures may macerate.
    •  Interdigital spaces (between toes), axillae, groins, and submammary area.
  10. 10
    • 1. In Nepal, minimum age at which an individual is responsible for his criminal act is:
    • a. 10 years
    • b. 12 years
    • c. 16 years
    • d. 21 years

    • Ans: a
    • The Act Relating to Children, 2075 (2018)
    •  If the child is less than ten years of age at the time of commission of the offence, no case and punishment of any kind shall be instituted against and imposed on him or her.
    •  If a child of ten years of age or above but below fourteen years of age commits an offence that is punishable by a fine, the child shall be released after counseling him or her and if such a child commits an offence that is punishable by imprisonment, the child shall be punished with imprisonment for upto six months or be sent to the child reform home for a period not exceeding one year without subjecting him or her to imprisonment.
    •  If a child of fourteen years of age or above but below sixteen years of age commits an offence, the child shall be punished with half the punishment that is imposable on the person having attained majority pursuant to the prevailing law.
    •  If a child of sixteen years of age or above but below eighteen years of age commits an offence, the child shall be punished with two-thirds of the punishment that is imposable on the person of legal age pursuant to the prevailing law.

    • 2. A textile industry worker had occasional chest tightness in early-stage and then regular chest tightness toward the end of the first day of the workweek. He is probably suffering from
    • a. Farmers lung
    • b. Byssinosis
    • c. Coal workers pneumonia
    • d. Asbestosis

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1980
    • Byssinosis
    • • Workers occupationally exposed to cotton dust (but also to flax, hemp, or jute dust) in the production of yarns for textiles and rope making are at risk for an asthma-like syndrome known as byssinosis. The risk of byssinosis is associated with both cotton dust and endotoxin levels in the workplace environment.
    • • Byssinosis is characterized clinically as occasional (early-stage) and then regular (late-stage) chest tightness toward the end of the first day of the workweek (“Monday chest tightness”). Exposed workers may show a significant drop in FEV1 over the course of a Monday workshift.
    • • Initially the symptoms do not recur on subsequent days of the week, but in a subset of workers, chest tightness may recur or persist throughout the workweek. After >10 years of exposure, workers with recurrent symptoms are more likely to have an obstructive pattern on pulmonary function testing.

    • 3. Which of the following vitamin deficiencies is seen in ileal resection?
    • a. Folate
    • b. Vitamin B12
    • c. Iron
    • d. Vitamin A

    • Ans: b
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 283, 122
    • Resection of ileum results in a significant enhancement of gastric motility and acceleration of intestinal transit. Following ileal resection, the colon receives a much larger volume of fluid and electrolytes and it also receives bile salts, which reduce its ability to absorb salt and water, resulting in diarrhoea. Even the loss of 100 cm of ileum may cause steatorrhoea, which can necessitate the administration of oral cholestyramine to bind bile salts. With larger resections (>100 cm) dietary fat restriction may be necessary.
    • Regular parenteral vitamin B12 is required.
    • Ileal resection may be complicated by vitamin B12 deficiency, malabsorption of fat-soluble vitamins, gallstones, renal oxalate stones and perianastomotic ulceration.

    • 4. A 23 year old female presented in emergency with sudden onset of severe throbbing headache and altered sensorium while pushing a car, on examination her BP is recorded to be 210/110 mm Hg. The most likely diagnosis is
    • a. Migraine headache
    • b. Subarachnoid hemorrhage
    • c. Cluster headache
    • d. Tension headache

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1785
    • • Most unruptured intracranial aneurysms are completely asymptomatic. Symptoms are usually due to rupture and resultant SAH, although some unruptured aneurysms present with mass effect on cranial nerves or brain parenchyma.
    • • At the moment of aneurysmal rupture with major SAH, the ICP suddenly rises. This may account for the sudden transient loss of consciousness that occurs in nearly half of patients.
    • • Sudden loss of consciousness may be preceded by a brief moment of excruciating headache, but most patients first complain of headache upon regaining consciousness. In 10% of cases, aneurysmal bleeding is severe enough to cause loss of consciousness for several days. In ~45% of cases, severe headache associated with exertion is the presenting complaint. The patient often calls the headache “the worst headache of my life”; however, the most important characteristic is sudden onset.
    • • Occasionally, these ruptures may present as headache of only moderate intensity or as a change in the patient’s usual headache pattern. The headache is usually generalized, often with neck stiffness, and vomiting is common.

    • Presentation:
    • • Patients typically present with a thunderclap headache, described as a sudden-onset headache that is the worst headache of their life. It is often associated with photophobia and meningism. Focal neurological deficits often present either at the same time as a headache or soon thereafter.
    • • In a substantial number of patients (almost half), it is associated with collapse and decreased or loss of consciousness, even in those patients who subsequently regain consciousness and have a good grade.
    • • Patients can be graded into five groups based on their clinical presentation, using the commonly employed Hunt and Hess grading system, which is predictive of outcome.
  11. 11
    • 1. Miosis is key clinical feature in which of the following poisoning?
    • a. Opioids
    • b. Anticholinergics
    • c. Sympathomimetics
    • d. Alcohol

    • Ans: a
    • Ref: OP Ghai Pediatrics 9th Edition, Page No: 708
    • • Miosis: Opioids, organophosphates
    • • Mydriasis: Anticholinergics, sympathomimetics
    • • Nystagmus: Phenytoin, alcohol, ketamine, sedative-hypnotics

    • 2. In a child with tetralogy of Fallot with fever and diarrhoea, which of the following is the surest sign of cyanotic spell?
    • a. Hepatomegaly
    • b. Absence of murmur
    • c. S3 gallop rhythm
    • d. Arterial O2 saturation <75%

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 2212
    • Paroxysmal hypercyanotic attacks (hypoxic, “blue,” or “tet” spells) are a particular problem during the 1st 2 yr of life. The infant becomes hyperpneic and restless, cyanosis increases, gasping respirations ensue, and syncope may follow. The spells occur most frequently in the morning on initially awakening or after episodes of vigorous crying. Temporary disappearance or a decrease in intensity of the systolic murmur is usual as flow across the right ventricular outflow tract diminishes. The spells may last from a few minutes to a few hours. Short episodes are followed by generalized weakness and sleep. Severe spells may progress to unconsciousness and, occasionally, to convulsions or hemiparesis.

    • 3. Aversion therapy is used for:
    • a. Depression
    • b. Mania
    • c. Transvestism
    • d. Suicidal tendencies

    • Ans: c
    • Ref: Niraj Ahuja Psychiatry 7th Edition, Page No: 215
    • Aversion Therapy
    • • Aversion therapy is used for the treatment of conditions which are pleasant but felt undesirable by the patient, e.g. alcohol dependence, transvestism, ego dystonic homosexuality, other sexual deviations. The underlying principle is pairing of the pleasant stimulus (such as alcohol) with an unpleasant response (such as brief electrical stimulus), so that even in absence of unpleasant response (after the therapy is over), the pleasant stimulus becomes unpleasant by association. The unpleasant aversion can be produced by electric stimulus (low voltage), drugs (such as apomorphine and disulfiram) or even by fantasy (when it is called as covert sensitization).
    • • Typically, 20-40 sessions are needed, with each session lasting about 1 hour. After completion of treatment, booster sessions may be given. The current use of aversion therapy has declined sharply in the Western world (and also elsewhere) as it is felt by many that it may violate the human rights of the patient.

    • 4. Which of the following increases gastric HCl secretion?
    • a. Adrenalectomy
    • b. Omeprazole
    • c. Gastric distension
    • d. Duodenal pH less than 4.0

    • Ans: c
    • Ref: Ganong Review of Medical Physiology, Lange; 24th Edition, Page No: 459
    • • However, before the meal enters the stomach, there are few additional triggers and thus the amount of secretion is limited. Once the meal is swallowed, on the other hand, meal constituents trigger substantial release of gastrin and the physical presence of the meal also distends the stomach and activates stretch receptors, which provoke a “vago-vagal” as well as local refl exes that further amplify secretion.
    • • The presence of the meal also buffers gastric acidity that would otherwise serve as a feedback inhibitory signal to shut off secretion secondary to the release of somatostatin, which inhibits both G and ECL cells as well as secretion by parietal cells themselves. Th is probably represents a key mechanism whereby gastric secretion is terminated after the meal moves from the stomach into the small intestine.
  12. 12
    • 1. Forster–Fuchs spot are seen in:
    • a. Macula in myopia
    • b. Choroid in myopia
    • c. Macula in hypermetropia
    • d. Choroid in hypermetropia

    • Ans: a
    • Ref: Parson Ophthalmology 22ndEdition, Page No: 613
    • • Axial ametropia is most common. In myopia the axial length of eyeball increases and in hypermetropia decreases.
    • • Forster–Fuchs spot at the macula is seen in myopia.
    • • Optical axis passes through centres of cornea, lens and retina. Visual axis passes through fixation point (object) to fovea.
    • • Aniseikonia is defined as condition where the images projected on the visual cortex from the two retinae are abnormally unequal in size or shape.
    • • Accommodative inertia refers to delay in response of accommodation. Normal accommodative change occurs in 1 second.

    • 2. Not true about peribulbar block is:
    • a. Intraocular anaesthesia and analgesia
    • b. Less optic nerve damage
    • c. Akinesia is not as good as in retrobulbar block
    • d. No risk of vascular damage

    • Ans: d
    • Ref: Parson Ophthalmology 22ndEdition, Page No: 606
    • Peribulbar block:
    • • Peribulbar blocks are employed for intraocular anaesthesia and analgesia, and have now almost replaced retrobulbar block.
    • • They are considered to cause less optic nerve damage, but the akinesia produced is not as good as in retrobulbar block.
    • • As two injections are given the likelihood of vascular damage persists.

    • 3. Anterior lenticonus is seen in:
    • a. Alport’s syndrome
    • b. Lowe's syndrome
    • c. Down's syndrome
    • d. William's syndrome

    • Ans: a
    • Ref: Kanski’s Clinical Ophthalmology: A systematic approach; 8th edition; Page No: 303
    • Anterior lenticonus consists of a bilateral axial projection of the anterior surface of the lens into the anterior chamber. Almost all patients have Alport syndrome, a hereditary condition characterized by progressive sensorineural deafness and renal disease associated with abnormal glomerular basement membrane; retinal flecks and posterior polymorphous corneal dystrophy may also occur.

    • 4. Neurotrophic keratopathy is caused by:
    • a. Bell's palsy
    • b. Facial nerve palsy
    • c. Trigeminal nerve palsy
    • d. None of the above

    • Ans: c
    • Ref: AK Khurana Ophthalmology 6th Edition, Page No: 114
    • Neurotrophic keratopathy
    • Neurotrophic keratopathy occurs due to decreased corneal sensations owing to damage of sensory nerve supply of the cornea.
    • Causes
    • A. Congenital
    • • Familial dysautonomia (Riley-Day syndrome).
    • • Congenital insensitivity to pain.
    • • Anhidrotic ectodermal dysplasia.
    • B. Acquired
    • • Following alcohol-block or electrocoagulation of Gasserian ganglion or section of the sensory root of trigeminal nerve for trigeminal neuralgia.
    • • A neoplasm pressing on Gasserian ganglion.
    • • Gasserian ganglion destruction due to acute infection in herpes zoster ophthalmicus.
    • • Acute infection of Gasserian ganglion by herpes simplex virus.
    • • Syphilitic (Luetic) neuropathy.
    • • Involvement of corneal nerves in leprosy, diabetes.
    • • Injury to Gasserian ganglion.
  13. 13
    • 1. A 24 year old male is admitted under your supervision in a critical care unit. He has been on hunger strike for last 10 days. Media wants to know about the situation of the person. What will you do?
    • a. Give information
    • b. Take consent from the patent before revealing any information
    • c. Scold and ask not to make unnecessary crowding
    • d. Give basic information only

    • Ans: b
    • Confidentiality
    •  The duty of confidentiality is important in building trust but it is not absolute.
    •  It can be overridden if non-disclosure seriously harms others.
    •  As with other patients, hunger strikers’ confidentiality should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm.
    •  If individuals agree, their relatives and legal advisers should be kept informed of the situation.

    • 2. Post partum VVF is best repaired after
    • a. 6 weeks
    • b. 8 weeks
    • c. 3 months
    • d. 6 months

    • Ans: c
    • Ref: Dutta Gynecology 6th Edition, Page No: 421
    • Definitive surgery (Old obstetric VVF)
    • • The ideal time of surgery is after 3 months following delivery. By this time, the general condition improves and local tissues are likely to be free from infection.
    • • Further delay is likely to produce more fibrosis and unnecessary prolongs the misery of the patient. Early repair may compromise the success.
    • • Surgical fistula if recognized within 24 hours, immediate repair may be done provided it is small. Otherwise it should be repaired after 10–12 weeks.
    • • Radiation fistulae should be repaired after 12 months.

    • 3. Pseudofracture are seen in which of the following?
    • a. Osteomalacia
    • b. Osteogenesis Imperfecta
    • c. Osteoporosis
    • d. Osteoid Osteoma

    • Ans: a
    • Ref: Maheshwari Orthopedics 5th Edition Page No: 312
    • Osteomalacia, which means softening of bones, is the adult counterpart of rickets. It is primarily due to deficiency of vitamin D. This results in failure to replace the turnover of calcium and phosphorus in the organic matrix of bone. Hence, the bone content is demineralised and the bony substance is replaced by soft osteoid tissue.
    • Radiological examination: Plain X-rays appear to be of ‘poor quality’ i.e., not sharp and well defined.
    • Following findings may be present:
    •  Diffuse rarefaction of bones.
    •  Looser's zone (pseudo-fractures) : These are radiolucent zones occurring at sites of stress. Common sites are the pubic rami, axillary border of scapula, ribs and the medial cortex of the neck of the femur. These are caused by rapid resorption and slow mineralisation and may be surrounded by a collar of callus.
    •  Triradiate pelvis in females.
    •  Protrusio-acetabuli i.e., the acetabulum protruding into the pelvis.

    • 4. Which of the following was not a component of Ottawa charter:
    • a. Build healthy public policy
    • b. Disseminate health insurance
    • c. Strengthen community action for health
    • d. Develop personal skills

    • Ans: b
    • Ref: Park PSM 23rd Edition, Page No: 31
    • The Ottawa charter incorporates five key action areas in health promotion. They are:
    • • Build healthy public policy,
    • • Create supportive environment for health,
    • • Strengthen community action for health,
    • • Develop personal skills, and
    • • Re-orient health services
  14. 14
    • 1. 62 years old man is brought by her daughter with complains of memory problem. He often wanders in the streets being unable to identify his home and his relatives. He also has difficulties with gait and balance. Also associated with difficulty with fine motor skills such as writing and dressing, he is diagnosed as Alzheimer’s disease. This condition is thought to be associated with abnormalities in presenilin genes which are located in:
    • a. Chromosomes 21 and X
    • b. Chromosomes 1 and 14
    • c. Chromosomes 5 and 18
    • d. Chromosomes 7 and 13

    • Ans: B, Chromosomes 1 and 14
    • Ref, BRS Behavioral Science, 7th edition, page no. 146
    • Alzheimer’s disease
    • -Patients with Alzheimer’s disease show a gradual loss of memory and intellectual abilities. Their psychiatric symptoms include inability to control impulses and lack of judgment as well as depression and anxiety.
    • -Later in the illness, symptoms include confusion and psychosis that progress to coma and death (usually within 8–10 years of diagnosis).
    • -For patient management and prognosis, it is important to make the distinction between Alzheimer’s disease and both pseudodementia (depression that mimics dementia) and behavioral changes associated with normal aging.

    • Genetic associations in Alzheimer’s disease include:
    • -Abnormalities of chromosome 21 (Down’s syndrome patients ultimately develop Alzheimer’s disease).
    • -Abnormalities of chromosomes 1 and 14 (sites of the presenilin 2 and presenilin 1 genes, respectively) implicated particularly in early onset Alzheimer’s disease (i.e., occurring before the age of 65).
    • -Possession of at least one copy of the apolipoprotein E4 (apoE4) gen e on chromosome 19.
    • -Gender—there is a higher occurrence of Alzheimer’s disease in women.


    • 2. One of the researcher measures progesterone level in 1000 volunteers who are normal adults (equal proportion of males and females). After measurements in each individual, the mean progesterone level for females comes out to be around 0.9ng/mL. What could be the normal average progesterone level for the group of male volunteers?
    • a. 0 ng/mL
    • b. 0.3 ng/mL
    • c. 0.9ng/mL
    • d. 2ng/mL

    • Ans: B, 0.3ng/mL
    • Ref, Ganong’s Review of Medical Physiology, 26th edition, page no. 401
    • Levels of progesterone in male and female
    • -In men, the plasma progesterone level is approximately 0.3 ng/mL (1 nmol/L).
    • -In women, the level is approximately 0.9 ng/mL (3 nmol/L) during the follicular phase of the menstrual cycle.
    • -The difference is due to secretion of small amounts of progesterone by cells in the ovarian follicles; theca cells provide pregnenolone to the granulosa cells, which convert it to progesterone.
    • -Late in the follicular phase, progesterone secretion begins to increase.
    • -During the luteal phase, the corpus luteum produces large quantities of progesterone and plasma progesterone is markedly increased to a peak value of approximately 18 ng/mL (60 nmol/L).


    • 3. One of the hunger striker makes a written document refusing treatment during his hunger strike. After 7 days of strike without eating or drinking anything, not even a cup of water, he becomes unresponsive. As medical personnel, you happen to be called for the management of victim. What will you do?
    • a. Do not do anything
    • b. Just take the vitals and make note of it
    • c. Perform resuscitation without anybody’s consent
    • d. Ask the police to take over

    • Ans: C, Perform resuscitation without anybody’s consent
    • Ref, Code of Ethics, NMC 2017
    • -A mentally sound patient has the right to refuse to consent to treatment, provided that he is able to exercise his judgment freely.
    • -The refusal should be respected and clearly documented. However, in case of Hunger strike, medical practitioner may intervene and provide lifesaving treatment to the striker without her/his consent if the striker becomes unconscious or his ability of fair judgment is compromised due to physiological changes brought by starvation.
    • -The treatment of such striker should be done according to the World Medical Association’s Declaration on Hunger Strikers.


    • 4. Prickly heat (aka Miliria is caused by):
    • a. Infection
    • b. Allergic reaction to heat
    • c. Obstruction of sebaceous duct
    • d. Rupture of sweat ducts and spillage to adjoining tissues

    • Ans: D, Rupture of sweat ducts and spillage to adjoining tissues
    • Ref, Textbook of Dermatology and STDs, Neena Khanna, page no. 122
    • Miliria
    • Etiology
    • -Miliaria is caused by obstruction and rupture of eccrine sweat ducts resulting in spillage of sweat into adjoining tissues.
    • [Miliaria rubra]
    • -Patients usually complain of pricking or burning, more than itching.
    • -Small, erythematous papules, often surmounted by vesicles. The vesicles can be easily ruptured by “flicking the lesion”.
    • -Trunk, forehead, and extremities.
    • -Triggered by hot humid weather.
    • [Miliaria profunda]
    • -Larger erythematous papules.

    • Treatment
    • General measures
    • -Avoid hot humid environment. Air-conditioned environment is ideal.
    • -Avoid wearing synthetic garments; cottons are best because they absorb sweat. Remember not only the undergarments but even top wear should be cotton.

    • Specific treatment
    • -Calamine lotion is soothing.
    • -For severely symptomatic patients, application of low-mid potency topical steroid for a few days gives symptomatic relief.
  15. 15
    • 1. In Valvular Aortic stenosis poorest prognosis is indicated when:
    • a. Angina occurs
    • b. Syncope occurs
    • c. Dyspnoea occurs
    • d. Palpitation occurs

    • Ans,c. Dyspnoea occurs
    • Ref: Harrison’s 18th ed./p.1939
    • • Death in patients with severe AS occurs most commonly in the seventh and eighth decades.
    • • The average time to death after the onset of various symptoms are described as follows.
    • • Angina pectoris-3 years; Syncope-3 years; Dyspnea - 2 years; Congestive heart failure - 1.5 to 2 years.
    • • Congestive heart failure was considered to be the cause of death in one-half to two-thirds of patients.
    • • Among adults dying with valvular AS, sudden death, which presumably resulted from an arrhythmia, occurred in 10 to 20% and at an average age of 60 years.

    • 2. Cryoglobulinemic vasculitis is related to which of the following:
    • a. Hepatitis A
    • b. Hepatitis B
    • c. Hepatitis C
    • d. Hepatitis E

    • Ans,c. Hepatitis C
    • Ref: Harrison’s 18th/e.p. 2798
    • • Cryoglobulins are cold-precipitable monoclonal or polyclonal immunoglobulins.
    • • Cryoglobulinemia may be associated with a systemic vasculitis characterized by palpable purpura, arthralgias, weakness, neuropathy, and glomerulonephritis.
    • • Although this can be observed in association with a variety of underlying disorders including multiple myeloma, lymphoproliferative disorders, connective tissue diseases, infection, and liver disease, in many instances it appeared to be idiopathic.
    • • Because of the apparent absence of an underlying disease and the presence of cryoprecipitate containing oligoclonal/polyclonal immunoglobulins, this entity was referred to as essential mixed cryoglobulinemia.
    • • Since the discovery of hepatitis C, it has been established that the vast majority of patients who were considered to have essential mixed cryoglobulinemia have cryoglobulinemic vasculitis related to hepatitis C infection.

    • 3. Aspirin is useful in which type of bone tumor:
    • a. Osteonecrosis
    • b. Osteopetrosis
    • c. Osteoid osteoma
    • d. Ewing’s sarcoma

    • Ans,c. Osteoid osteoma
    • Ref: Maheshwari 5th ed. / p.235
    • • Osteoid osteoma is a benign bone tumor characterized by pain which is relieved by non-steroidal anti- inflammatory drugs (NSAIDs), such as aspirin.
    • • To clarify the mechanism of the pain, five osteoid osteomas were studied immune-histochemically using polyclonal antibodies against prostaglandin E2 (PGE2), S-100 protein and protein gene product.
  16. 16
    • Q1. Surgical landmark for endolymphatic sac during surgery is:
    • a. Solid angle
    • b. Trautman triangle
    • c. Utelli's angle
    • d. Donaldson line

    • Ans: D
    • Ref. Essential of Mohan Bansal, page no.12
    • 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. Ans is d i.e. Donaldson 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 petrol 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
    • Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no. 1060
    • 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
    • Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no. 93
    • •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).
  17. 17
    • 1. What are the cells which produce surfactant in the alveoli?
    • a. Type I pneumocytes
    • b. Type II pneumocytes
    • c. Macrophages
    • d. Interstitials fibroblasts

    • Ans: B, Type II pneumocytes
    • Ref, Ganong’s Review of Medical Physiology, 26th edition, page no. 611
    • Alveolar lining
    • - The alveoli are lined by two types of epithelial cells.
    • - Type I cells are flat cells with large cytoplasmic extensions and are the primary lining cells of the alveoli, covering approximately 95% of the alveolar epithelial surface area.
    • - Type II cells (granular pneumocytes) are thicker and contain numerous lamellar inclusion bodies. Although these cells make up only 5% of the surface area, they represent approximately 60% of the epithe¬lial cells in the alveoli.
    • - Type II cells are important in alveolar repair as well as other lung cellular functions. One prime func-tion of the type II cell is the production of surfactant.

    • 2. 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.
    • 10. Other Paraphilias: These include sexual arousal with urine (urophilia); faeces (coprophilia); enemas (klismaphilia); corpses (necrophilia), among many others.

    • 3. 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 or bronchitis, frequent greasy, bulky stools or 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.

    • 4. 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
    • 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.

    • 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.

    • 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.
  18. 18
    • 1. At what lung volume does the outward recoil of the chest wall equal the inward elastic recoil of the lung?
    • a. Expiratory reserve volume
    • b. Functional residual capacity
    • c. Residual volume
    • d. Tidal volume

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 306e-2
    • The functional residual capacity of the lung refers to the volume of air that remains in the lung following a normal tidal respiration. This volume of air represents the point at which the outward recoil of the chest wall is in equilibrium with the inward elastic recoil of the lungs. The lungs would remain at this volume if not for the actions of the respiratory muscles. The functional residual capacity is comprised of two lung volumes: the expiratory reserve volume and the residual volume. The expiratory reserve volume represents the additional volume of air that can be exhaled from the lungs when acted upon by the respiratory muscles of exhalation. The residual volume is the volume of air that remains in the lung following a complete exhalation and is determined by the closing pressure of the small airways.

    • 2. Time interval between inoculation of infection to maximum infectivity is:
    • a. Lead time
    • b. Median incubation period
    • c. Generation time
    • d. Serial interval

    • Ans: c
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 64,100,136
    • • "Lead time" is the advantage gained by screening, i.e., the period between diagnosis by early detection and diagnosis by other means
    • • Median incubation period", it is the time required for 50 per cent of the cases to occur following exposure.
    • • Generation time". It is defined as "the interval of time between receipt of infection by a host and maximal infectivity of that host"
    • • The gap in time between the onset of the primary case and the secondary case is called the "serial interval".

    • 3. A 72-year-old male is admitted to the hospital with complaints of severe chest pain radiating to his left arm. ECG examination provides evidence of significant myocardial infarction of the posterior wall of the left ventricle. Which of the following nerves is responsible for the radiation of pain to the arm during myocardial infarction?
    • a. Phrenic
    • b. Vagus
    • c. Intercostobrachial
    • d. Greater splanchnic

    • Ans: c
    • Ref: Gray’s Anatomy for Students, 213-222
    • • The intercostobrachial nerve is the lateral cutaneous branch of the second intercostal nerve. It serves a sensory function both in the thoracic wall and medial aspect of the arm.
    • • The phrenic nerve arises from spinal nerves C3 to C5 and innervates the diaphragm. This nerve has no branches that pass into the arm.
    • • The vagus nerve is CN X and is a major supplier of autonomic function to the gut, up to the left colic flexure, and also provides some autonomic motor and sensory supply to organs in the head, neck, and thorax.
    • • The greater thoracic splanchnic nerve originates in the thorax from the sympathetic chain at the levels of T5 to T9 and innervates abdominal structures.

    • 4. Anaphylatoxins are:
    • a. C3a and C3b
    • b. C3b and C5b
    • c. C3a and C5a
    • d. C5a and C5b

    • Ans: c
    • Ref: Jawetz’s Medical Microbiology; Lange; 27th Edition, Page No: 141
    • Anaphylatoxins promote vasodilation and increase vascular permeability.
    • Two complement components, C3a and C5a, are potent anaphylatoxins.
    • Both bind to receptors on mast cells and basophils triggering them to release histamine. This event results in an increased blood flow to the site of infection, allowing more complement, antibodies, and immune cells to enter the site of infection.
  19. 19
    • 1. A woman with a twin pregnancy has delivered the first twin without any complications one hour ago. The second twin is in the transverse lie. The liquor content is reduced and there are strong uterine contractions. The cervix is fully dilated and the membranes are absent. The shoulder is felt. The foetal heart rate is 140 bpm. What is the most appropriate management?
    • a. Observe for one hour for spontaneous version to occur
    • b. Perform a caesarean section immediately
    • c. Perform an external cephalic version
    • d. Perform an internal version

    • Ans: b
    • External version is contraindicated because of the long interval after the delivery of the first twin, reduction of liquor and presence of frequent uterine contractions.
    • Internal version and breech extraction are traumatic procedures, which are even more dangerous in the presence of the above complications. Therefore, performing a caesarean section is the best management option. Spontaneous version will not occur at this stage.

    • 2. Triple bonds are found between which base pairs:
    • a. A-T
    • b. C-G
    • c. A-G
    • d. C-T

    • Ans: b
    • Ref: Harper Biochemistry 30th Edition, Page No: 361
    • DNA rich in G–C pairs, which have three hydrogen bonds, melts at a higher temperature than that rich in A–T pairs, which have two hydrogen bonds.

    • 3. Which one of the following is associated with Testicular torsion?
    • a. Kudos Test
    • b. Bell Clapper Deformity
    • c. McBurney’s Test
    • d. Kernig’s Test

    • Ans: b
    • Ref: Nelson pediatrics, 20th Edition, Page No: 2595
    • Testicular (spermatic cord) torsion
    • • Testicular torsion requires prompt diagnosis and treatment to salvage the testis. Torsion is the most common cause of testicular pain in boys age 12 yr and older, and is uncommon before age 10 yr.
    • • It is caused by inadequate fixation of the testis within the scrotum, resulting from a redundant tunica vaginalis, allowing excessive mobility of the testis.
    • • The abnormal attachment is termed a bell clapper deformity and often is bilateral.
    • • Shortly after torsion occurs, venous congestion begins and subsequently arterial flow is interrupted.
    • • The likelihood of testis survival depends on the duration and severity of torsion.
    • • Following 4-6 hr of absent blood flow to the testis, irreversible loss of spermatogenesis can occur.
    • • Torsion may be familial in approximately 10% of males.


    • 4. Adductor canal contains all except:
    • a. Femoral artery
    • b. Femoral vein
    • c. Saphenous nerve
    • d. Nerve to vastus lateralis

    • Ans: d
    • Ref: Snell Clinical Anatomy; 9th edition; Page No: 457
    • Adductor (Subsartorial) Canal
    • The adductor canal is an intermuscular cleft situated on the medial aspect of the middle third of the thigh beneath the Sartorius muscle. It commences above at the apex of the femoral triangle and ends below at the opening in the adductor magnus.
    • • The anteromedial wall is formed by the sartorius muscle and fascia.
    • • The posterior wall is formed by the adductor longus and magnus.
    • • The lateral wall is formed by the vastus medialis.
    • The adductor canal contains the terminal part of the femoral artery, the femoral vein, the deep lymph vessels, the saphenous nerve, the nerve to the vastus medialis, and the terminal part of the obturator nerve.

    • 5. Management of flail chest with respiratory failure is:
    • a. Chest tube drainage
    • b. Oxygen administration
    • c. IPPV
    • d. Internal operative fixation of the fractures segments

    • Ans: c
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 368
    • Currently, treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy. If a chest tube is in situ, topical intrapleural local analgesia introduced via the tube, can also be used. Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilise the flail segment using internal fixation of the ribs may be useful in a selected group of patients with isolated or severe chest injury and pulmonary contusion.

    • 6. A 21-year-old girl is 9 weeks pregnant and requests an abortion. What will you do?
    • a. Discuss about the possible complications
    • b. Discuss about the surgical technique
    • c. Ask for the parental or husband consent
    • d. All of the above

    Ans: a

    • Abortion law update Nepal
    • Ref: Lawcommission Gov website
    • The Right to Safe Motherhood and Reproductive Health Act, 2075 (2018)
    • Chapter 4: Safe Abortion
    • To perform safe abortion: A pregnant woman shall have the right to get safe abortion performed in any of the following circumstances:
    • a. Fetus (gestation) up to twelve weeks, with the consent of the pregnant woman,
    • b. Fetus (gestation) up to twenty-eight weeks, as per the consent of such woman, after the opinion of the licensed doctor that there may be danger upon the life of the pregnant woman or her physical or mental health may deteriorate or disabled infant may be born in case the abortion is not performed,
    • c. Fetus (gestation) remained due to rape or incest, fetus (gestation) up to twenty-eight weeks with the consent of the pregnant woman,
    • d. Fetus (gestation) up to twenty-eight weeks with the consent of the woman who is suffering from H.I.V. or other incurable disease of such nature,
    • e. Fetus (gestation) up to twenty eight weeks with the consent of the woman, as per the opinion of the health worker involved in the treatment that damage may occur in the womb due to defects occurred in the fetus (gestation), or that there is such defect in the fetus of the womb that it cannot live even after the birth, that there is condition of disability in the fetus (gestation) due to genetic defect or any other cause.
  20. 20
    • 1. Phage mediate transfer of cDNA into host is known as:
    • a. Transduction
    • b. Transformation
    • c. Transmission
    • d. Conjugation

    • Ans: a
    • Ref: Jawetz’s Medical Microbiology; Lange; 27th Edition, Page No: 111
    •  Conjugation requires donor cell-to-recipient cell contact to transfer only one strand of DNA. The recipient completes the structure of dsDNA by synthesizing the strand that complements the strand acquired from the donor.
    •  In transduction, donor DNA is carried by a phage coat and is transferred into the recipient by the mechanism used for phage infection.
    •  Transformation, the direct uptake of “naked” donor DNA by the recipient cell, may be natural or forced. Forced transformation is induced in the laboratory, where, after treatment with high salt and temperature shock, many bacteria are rendered competent for the uptake of extracellular plasmids.

    • 2. All of the following heart sounds are heard in chronic Mitral stenosis except?
    • a. Mid diastolic murmur
    • b. Third heart sound
    • c. Opening snap
    • d. Loud S1

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1813
    • Auscultation findings in MS:
    • • The first heart sound (S1) is usually accentuated in the early stages of the disease and slightly delayed.
    • • The pulmonic component of the second heart sound (P2) also is often accentuated with elevated PAPs, and the two components of the second heart sound (S2) are closely split.
    • • The opening snap (OS) of the mitral valve is most readily audible in expiration at, or just medial to, the cardiac apex.
    • • This sound generally follows the sound of aortic valve closure (A2) by 0.05–0.12 s. The time interval between A2 and OS varies inversely with the severity of the MS.
    • • The OS is followed by a low-pitched, rumbling, diastolic murmur, heard best at the apex with the patient in the left lateral recumbent position, it is accentuated by mild exercise (e.g., a few rapid sit-ups) carried out just before auscultation.
    • • In general, the duration of this murmur correlates with the severity of the stenosis in patients with preserved CO. In patients with sinus rhythm, the murmur often reappears or becomes louder during atrial systole (presystolic accentuation).
    • • Soft, grade I or II/VI systolic murmurs may be heard at or medial to the apex and may signify mixed mitral valve disease with regurgitation.
    • • Hepatomegaly, ankle edema, ascites, and pleural effusion, particularly in the right pleural cavity, may occur in patients with MS and RV failure.

    • 3. All of the following are pre-malignant except:
    • a. Crohn’s disease
    • b. Ulcerative colitis
    • c. Peutz-Jegher’s syndrome
    • d. Barrett’s esophagus

    • Ans: c
    • Ref: Bailey and Love’s Short Practice of Surgery 26th Edition, Page No: 1159
    • Peutz–Jeghers syndrome:
    • This is an autosomal dominant disease characterized by melanosis of the mouth and lips and multiple hamartomatous (benign tumour-like malformation resulting from faulty development in an organ) polyps in the small bowel and colon .
    • Malignant change in the polyps rarely occurs and, in general the polyps can be left alone. Resection may be indicated for heavy and persistent or recurrent bleeding or intussusception. Polyps may be removed by enterotomy, or, at laparotomy, snared via a colonoscope introduced via an enterotomy.
    • Heavily involved segments of small intestine may occasionally be resected.

    • 4. Fluid and electrolyte balance of the body is maintained by balancing between intake and output. Kidneys are the major source of excretion which not only remove the extra fluids and electrolytes but also the unwanted metabolic products which are hazardous if retained in the body. What is the minimum obligatory urine volume in a day for a normal human adult?
    • a. 0.3L/day
    • b. 0.5L/day
    • c. 0.8L/day
    • d. 1.0L/day

    • Ans: b
    • Ref: Guyton and Hall Textbook of Medical Physiology, Elsevier; 13th Edition, Page No: 373
    • • The maximal concentrating ability of the kidney dictates how much urine volume must be excreted each day to rid the body of metabolic waste products and ions that are ingested.
    • • A normal 70-kilogram human must excrete about 600 milliosmoles of solute each day. If maximal urine concentrating ability is 1200 mOsm/L, the minimal volume of urine that must be excreted, called the obligatory urine volume can be calculated by dividing 600 mOsm/day by 1200 mOsm/L, i.e. 0.5L/day.
  21. 21
    • 1. A 65-year-old male complains of severe back pain and inability to move his left lower limb. Radiographic studies demonstrate the compression of nerve elements at the intervertebral foramen between vertebrae L5 and S1. Which structure is most likely responsible for this space-occupying lesion?
    • a. Anulus fibrosus
    • b. Nucleus pulposus
    • c. Posterior longitudinal ligament
    • d. Anterior longitudinal ligament

    • Ans: b
    • Ref: Gray’s Anatomy for Students, 79-81
    • • Compression of nerves at the intervertebral foramen indicates a disk herniation. A disk herniation is characterized by protrusion of the nucleus pulposus from the anulus fibrosus posterolaterally into the spinal canal or intervertebral foramen.
    • • The ligaments may be affected by the herniation but are not responsible for the compression of the spinal nerve roots.

    • 2. Cremasteric fascia is continuation of:
    • a. External oblique
    • b. Fascia transversalis
    • c. Internal oblique
    • d. Rectus abdominis

    • Ans: c
    • Ref: Snell Clinical Anatomy; 9th edition; Page No: 129-130
    • Coverings of the Spermatic Cord (the Spermatic Fasciae)
    • The coverings of the spermatic cord are three concentric layers of fascia derived from the layers of the anterior abdominal wall. Each covering is acquired as the processus vaginalis descends into the scrotum through the layers of the abdominal wall
    • • External spermatic fascia derived from the external oblique aponeurosis and attached to the margins of the superficial inguinal ring.
    • • Cremasteric fascia derived from the internal oblique muscle.
    • • Internal spermatic fascia derived from the fascia transversalis and attached to the margins of the deep inguinal ring.

    • 3. Root value of ankle jerk is:
    • a. L3 - L4
    • b. S1 - S2
    • c. L4 - L5
    • d. L2 - L3

    • Ans: b
    • Ref: Moore's Clinically Oriented Anatomy; 7th Edition, Page No: 607
    • The ankle jerk reflex, or triceps surae reflex, is a calcaneal tendon reflex. It is a myotatic reflex elicited while the person’s legs are dangling over the side of the examining table. The calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus. The normal result is plantar flexion of the ankle joint. The calcaneal tendon reflex tests the S1 and S2 nerve roots. If the S1 nerve root is injured or compressed, the ankle reflex is virtually absent.

    • 4. A 47-year-old female is admitted to the hospital with jaundice and epigastric pain that migrates toward the patient’s right side and posteriorly toward the scapula. Radiographic examination reveals cholecystitis with a large gallstone. Which of the following is the most likely site for a gallstone to lodge?
    • a. Common bile duct
    • b. Hepatopancreatic ampulla
    • c. Left hepatic duct
    • d. Pancreatic duct

    • Ans: b
    • Ref: Gray’s Anatomy for Students, 322
    • The hepatopancreatic ampulla is also known as the ampulla of Vater and is located at the junction of the pancreatic duct and common bile duct. It is the narrowest part of the ductal system. The common bile duct, left hepatic duct, pancreatic duct, and right hepatic duct all have larger diameters than the ampulla of Vater.
  22. 22
    • 1. What is aliskiren?
    • a. ACE inhibitor
    • b. Alpha blocker
    • c. Centrally acting sympathoplegic
    • d. Renin inhibitor

    • Ans: d
    • Ref: Katzung’s Basic & Clinical Pharmacology; Lange; 14th Edition, Page No: 192
    • • Aliskiren is an inhibitor of enzymatic action of renin. It reduces angiotensin I and II and aldosterone.
    • • Clinically use: hypertension
    • • Toxicity: Hyperkalemia, renal impairment, potential teratogen

    • 2. Which of the following doesn't cross placenta?
    • a. Morphine
    • b. Heparin
    • c. Warfarin
    • d. Naloxone

    • Ans: b
    • Ref:Goodman & Gilman’s Pharmacology; 13thedition; Pg: 589/ KD Tripathi; 7th edition; Pg 19
    • Unlike the oral anticoagulants, heparin, LMWH, and fondaparinux do not cross the placenta and have not been associated with fetal malformations, making them the drugs of choice for anticoagulation during pregnancy. Heparin, LMWH, and fondaparinux do not appear to increase fetal mortality or prematurity. If possible, the drugs should be discontinued 24 h before delivery to minimize the risk of postpartum bleeding.
    • Passage across Placenta
    • • Placental membranes are lipoidal and allow free passage of lipophilic drugs, while restricting hydrophilic drugs. The placental efflux P-gp and other transporters like BCRP, MRP3 also serve to limit foetal exposure to maternally administered drugs.
    • • Placenta is a site for drug metabolism as well, which may lower/modify exposure of the foetus to the administered drug. However, restricted amounts of nonlipid-soluble drugs, when present in high concentration or for long periods in maternal circulation, gain access to the foetus.
    • • Some influx transporters also operate at the placenta. Thus, it is an incomplete barrier and almost any drug taken by the mother can affect the foetus or the newborn (drug taken just before delivery, e.g. morphine).

    • 3. Ram Prasad is admitted to Hospital with respiratory infection for which antibiotic tobramycin is ordered. The clearance and volume of distribution Vd of tobramycin in him are 160 ml/min and 40 L, respectively. If you wish to give Ram Prashad an intravenous loading dose to achieve the therapeutic plasma concentration of 0.4 mg/dl rapidly, how much should be given?
    • a. 640 mg
    • b. 16 mg
    • c. 115.2 mg
    • d. 160 mg

    • Ans: d
    • Ref: Katzung’s Basic & Clinical Pharmacology; Lange; 14th Edition, Page No: 50, 51
    • Here
    • Target plasma concentration = .4 mg/dl= 4mg/L
    • Loading dose =Volume of distribution Vd × target plasma concentration
    • = 40×4
    • = 160 mg

    • 4. Estrogen replacement for postmenopausal symptoms causes an increase in:
    • a. LDL
    • b. VLDL
    • c. Cholesterol
    • d. Triglycerides

    • Ans: d
    • Ref: Katzung’s Basic & Clinical Pharmacology; Lange; 14th Edition, Page No: 725
    • Alterations in the composition of the plasma lipids caused by estrogens are characterized by an increase in the high-density lipoproteins (HDL), a slight reduction in the low-density lipoproteins (LDL), and a reduction in total plasma cholesterol levels. Plasma triglyceride levels are increased. Estrogens decrease hepatic oxidation of adipose tissue lipid to ketones and increase synthesis of triglycerides.
  23. 23
    • 1. mRNA start codon is:
    • a. UGA
    • b. AUG
    • c. UAA
    • d. UAG

    • Ans: b
    • • mRNA start codons AUG (or rarely GUG).
    • • mRNA stop codons UGA, UAA, UAG

    • 2. Which of the following drug targets CD20?
    • a. Alemtuzumab
    • b. Rituximab
    • c. Bevacizumab
    • d. Denosumab

    • Ans: b
    • • Alemtuzumab: CD52
    • • Rituximab: CD20
    • • Bevacizumab: VEGF
    • • Denosumab: RANKL

    • 3. Rubeola is caused by:
    • a. Coxsackievirus type A
    • b. Human herpesvirus 6
    • c. Measles virus
    • d. Parvovirus B19

    • Ans: c
    • Red rashes of childhood
    • • Coxsackievirus type A: Hand-foot-mouth disease
    • • Human herpesvirus 6: Roseola (exanthem subitum)
    • • Measles virus: Measles (rubeola)
    • • Parvovirus B19: Erythema infectiosum (fifth disease)
    • • Rubella virus: Rubella
    • • Streptococcus pyogenes: Scarlet fever
    • • Varicella-Zoster virus: Chickenpox

    • 4. Optic neuropathy may be caused by:
    • a. INH
    • b. Rifampicin
    • c. Pyrazinamide
    • d. Ethambutol

    • Ans: d
    • Ethambutol may cause optic neuropathy (red-green color blindness, usually reversible)

    • 5. Common age group for neuroblastoma is:
    • a. 3 years
    • b. 9 years
    • c. 15 years
    • d. 25 years

    • Ans: a
    • Neuroblastoma: Most common tumor of the adrenal medulla in children, usually < 4 years old. Originates from Neural crest cells. Occurs anywhere along the sympathetic chain.
  24. 24
    • 1. Politzer bag test is used to test
    • a. Eustachian tube
    • b. Larynx
    • c. Esophagus
    • d. Nasal cavity

    • Ans: a
    • Ref: PL Dhingra and Shruti Dhingra ENT and HNS 6th Edition, Page No: 59
    • Valsalva test: The principle of this test, as also of politzerization, is to build positive pressure in the nasopharynx so that air enters the eustachian tube.

    • 2. A male newborn presented with distension of abdomen and failure to pass meconium. Subsequently, a full-thickness biopsy of the rectum was performed. The rectal biopsy is likely to show.
    • a. Fibrosis of submucosa
    • b. Lack of ganglion cells
    • c. Thickened muscularis propria
    • d. Hyalinization of muscular coat

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1809
    • Congenital Aganglionic Megacolon (Hirschsprung Disease)
    • • A developmental disorder (neurocristopathy) of the enteric nervous system,
    • • Characterized by the absence of ganglion cells in the submucosal and myenteric plexus.
    • • Most common cause of lower intestinal obstruction in neonates, with an overall incidence of 1 in 5,000 live births.
    • • The male: female ratio for Hirschsprung disease is 4 : 1 for short segment disease, and approximately 2 : 1 with total colonic aganglionosis.
    • • Prematurity is uncommon
    • • Usually diagnosed in the neonatal period secondary to a distended abdomen, failure to pass meconium, and/or bilious emesis or aspirates with feeding intolerance

    • 3. Smooth brain means:
    • a. Anencephaly
    • b. Lissencephaly
    • c. Holoprosencephaly
    • d. Schizencephaly

    • Ans: b
    • Ref: USMLE Step 1 First Aid 2020, Page No: 491
    • Lissencephaly
    •  Failure of neuronal migration resulting in a “smooth brain” that lacks sulci and gyri.
    •  May be associated with microcephaly, ventriculomegaly.
    • Holoprosencephaly (HPE) is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres.
    • Schizencephaly is a rare cortical malformation that manifests as a grey matter lined cleft extending from the ependyma to the pia mater.

    • 4. Most common degeneration in fibroid is:
    • a. Hyaline
    • b. Cystic
    • c. Fat
    • d. Red

    • Ans: a
    • Ref: DC Dutta Textbook of Gynecology including Contraception; 6th Edition, Page No: 275
    • • Hyaline degeneration is the most common (65%) type of degeneration affecting all sizes of fibroids except the tiny one.
    • • It is common specially in tumors having more connective tissues.
    • • The central part of the tumor which is least vascular is the common site.
    • • The feel becomes soft elastic in contrast to firm feel of the tumor.
    • Red degeneration (carneous degeneration) occurs in a large fibroid mainly during second half of pregnancy and puerperium. Partial recovery is possible and as such called necrobiosis. The cause is not known but is probably vascular in origin. Infection does not play any part.
  25. 25
    • 1. Lateral zones of the hard palate are covered by:
    • a. Non keratinized epithelium, submucosal layer and minor salivary gland
    • b. Non keratinized epithelium, absent submucosal layer and minor salivary gland
    • c. Keratinized epithelium, submucosal layer and minor salivary gland
    • d. Keratinized epithelium, absent submucosal layer and minor salivary gland

    • Ans: c
    • Ref: IB Singh’s Human Histology, 6th Edition; Page No: 227
    • The wall of the oral cavity is made up partly of bone (jaws, hard palate), and partly of muscle and connective tissue (lips, cheeks, soft palate, and floor of mouth). These structures are lined by mucous membrane. The mucous membrane is lined by stratified squamous epithelium that rests on connective tissue, similar to that of the dermis.
    • The hard palate is lined by a keratinized squamous epithelium resting on a dense connective, whereas in the soft palate, the epithelium is parakeratinized and showed lymphocyte infiltration. The palate showed several pacinian corpuscles in the propria-submucosa.

    • 2. Three hours after a departmental party, eight interns and residents develop severe diarrhea. Other symptoms included nausea, vomiting, and abdominal cramps. Food served included chicken salad and cream-filled pastries. All affected individuals had the chicken salad. Which of the following is the most likely causative organism?
    • a. Staphylococcal enterotoxin
    • b. C. botulinum
    • c. Clostridium perfringens
    • d. Salmonella species

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 16th Edition, Page No: 819
    • Staphylococcal enterotoxin food poisoning is characterized by violent GI upset with severe nausea, cramps, vomiting, and diarrhea. It occurs very rapidly after ingestion (1–6 hours) and usually resolves by 12 hours.

    • 3. A 42-year-old executive has refractory chronic duodenal ulcer disease. His physician has suggested several surgical options. The patient has chosen a parietal (highly selective) vagotomy instead of a truncal vagotomy and antrectomy because?
    • a. It results in a lower incidence of ulcer recurrence
    • b. It benefits patients with antral ulcers the most
    • c. It reduces acid secretion to a greater extent
    • d. The complication rate is lower

    • Ans: d
    • In highly selective vagotomy, the nerve supply to the pylorus is left intact (and therefore no drainage procedure is necessary).
    • During this operation, the branches of the vagus nerve that supply the parietal cell mass are meticulously divided, leaving the main anterior and posterior nerves of Latarjet intact. The main vagal trunks are also left intact, thus sparing the nerve supply to the liver, gallbladder, pancreas, and intestines. To ensure completeness of the procedure, great care is taken to divide the proximal (criminal) nerve of Grassi. Although the complication rate is lower, the recurrence rate is higher than that of an antrectomy and truncal vagotomy.

    • 4. Total budget allocated for Health in Nepal in FY 2020-21 is:
    • a. 64 billion out of 1474 billion
    • b. 90 billion out of 1474 billion
    • c. 121 billion out of 1474 billion
    • d. 242 billion out of 1474 billion

    • Ans: b
    • Budget for health in FY 2020-21: 6.15 %
    • • Total budget: 14 Kharab 74 Arab 64 crore (1474.64 billion)
    • • Health budget: 90 Arab 69 Crore (90.69 billion)

    • 5. While treating a patient with eclampsia, at what serum level of magnesium does deep tendon reflex disappear?
    • a. > 5 mEq/L
    • b. > 7 mEq/L
    • c. > 10 mEq/L
    • d. > 12 mEq/L

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 273
    • • The therapeutic level of serum magnesium is 4–7 mEq/L.
    • • Serum magnesium levels may be monitored in selected cases (renal insufficiency, absent deep tendon reflexes).
    • • To control fits, optimum serum magnesium level is 4.8–8.4 mg/dL (4-7 mEq/L) to be maintained.

    • Magnesium toxicity and serum Mg level is seen as:
    • o loss of deep tendon reflexes > 7 mEq/L;
    • o respiratory depression more than 10 mEq/L and
    • o cardiac arrest more than 25 mEq/L.

    Magnesium sulfate is continued for 24 hours after the last seizure or delivery whichever is later.
  26. 26
    • 1. Which of the following is false regarding neoplastic compressive myelopathy?
    • a. Most neoplasms are subdural in origin
    • b. Thoracic spine is most commonly involved
    • c. Tumor does not cross the disk space to involve adjacent vertebral body
    • d. Prognosis is poor when motor deficits are established for > 48 hours

    • Ans: A. Most neoplasms are subdural in origin
    • Ref: Harrison’s Principles of Internal Medicine, 19th edition, p2653
    • Explanation:
    • - Any malignant tumour can metastasise to spinal columns, particularly tumours of breast, lung, prostate, kidney, lymphoma and myeloma.
    • - The most common site is the thoracic spinal column.
    • - Most neoplasms are epidural in origin, resulting from metastases to adjacent vertebral body.
    • - Unlike infections of the spinal column, the tumours do not cross the disk space.

    • 2. All are true about separation anxiety disorder except:
    • a. The prevalence is 3.5% to 5.4%
    • b. Comorbidity is common
    • c. Prevalence is higher in girls
    • d. Average age of onset is 4 years

    • Ans: D. Average age of onset in 4 years
    • Ref: Nelson Textbook of Pediatrics
    • Explanation:
    • - Separation anxiety disorder is a common childhood anxiety disorder.
    • - It has a prevalence is 3.5% to 5.4%.
    • - It is more common in girls.
    • - The average age of onset is 7.5 years.
    • - Children have unrealistic worries about separation from a major attachment figure.
    • - Comorbidity is common.
    • - Usually present with school refusal and physical complaints related to anxiety.

    • 3. Anaesthetic implication in Gaisbock’s syndrome is?
    • a. Postoperative respiratory failure
    • b. Risk of deep vein thrombosis
    • c. Renal dysfunction
    • d. Risk of aspiration

    • Ans: B. Risk of deep vein thrombosis
    • Ref: Lee’s Synopsis of Anaesthesia, 13th edition, p864
    • - Gaisbock’s syndrome is polycythemia due to reduction in plasma volume.
    • - It is usually seen in smokers, obese individuals and in patients with hypertension.
    • - Anaesthetic implications include cardiovascular problems and risk of deep vein thrombosis.
    • - May require venesection.

    • 4. Stocker’s line is seen in?
    • a. Pinguecula
    • b. Trachoma
    • c. Pterygium
    • d. Concretions

    • Ans: C. Pterygium
    • Ref: Comprehensive Ophthalmology, A. K. Khurana, 4th edition, p80.
    • - Pterygium is usually seen in elderly males and it presents as a triangular fold of conjunctiva which encroaches the cornea.
    • - It is usually seen on the nasal side.
    • - Stocker’s line is a deposition of iron seen in corneal epithelium anterior to advancing head of pterygium.
  27. 27
    • Q1. Abdominal approach is used in?
    • A. Thiersch operation
    • B. Delorme’s operation
    • C. Altemier’s procedure
    • D. Ripstein’s operation

    • Correct answer : D. Ripstein’s operation
    • Ripstein’s operation is the abdominal approach for rectal prolapse.
    • The abdominal approach is recommended in patients with complete rectal prolapse who are otherwise in good health.
    • In Ripstein’s operation, the rectosigmoid junction is hitched up to the front of the sacrum using a teflon sling.
    • Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 1225.

    • Q2. Lyre sign in seen in?
    • A. Grave’s disease
    • B. Meniere’s disease
    • C. Lateral sinus thrombosis
    • D. Carotid body tumour

    • Correct answer : D. Carotid body tumour
    • Lyre sign is an angiographic finding seen in carotid body tumour of the neck.
    • There is splaying apart of internal and external carotid arteries on angiogram.
    • Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p460.

    • Q3. Areas involved in posterior cerebral artery infarct are all except?
    • A. Thalamus
    • B. Temporal lobe
    • C. Anterior cortex
    • D. Choroid plexus

    • Correct answer : C. Anterior cortex
    • Blood supply of brain – Anterior cerebral artery (blue), middle cerebral artery (red) & posterior cerebral artery (yellow).
    • AREAS INVOLVED IN POSTERIOR CEREBRAL ARTERY INFARCT
    • Occipital lobe
    • Infero-medial temporal lobe
    • Postero-inferior parietal lobe
    • Large parts of thalamus
    • Midbrain
    • Posterior part of choroid plexus
  28. 28
    • 1. Which of the following does not pass through the deep inguinal ring?
    • a. Spermatic cord
    • b. Round ligament of uterus
    • c. Ilioinguinal nerve
    • d. None

    • Ans: C, Ilioinguinal nerve
    • Ref: Human anatomy BD Chaurasia 4th edition Vol 2 Page no. 208
    • Structures Passing through the Canal
    • 1. The spermatic cord in males, or the round ligament of the uterus in females, enters the inguinal canal through the deep inguinal ring and passes out through the superficial inguinal ring.
    • 2. The ilioinguinal nerve enters the canal through the interval between the external and internal oblique muscles and passes out through the superficial inguinal ring


    •  2. Adverse effects of heparin are all except
    • a. Bleeding
    • b. Reversible alopecia
    • c. Osteoporosis
    • d. Thrombocytosis

    • Ans: D, Thrombocytosis
    • Ref: Basic and clinical pharmacology Katzung 14th e Page no 613
    • Toxicity of Heparin
    • A. Bleeding and Miscellaneous Effects
    • The major adverse effect of heparin is bleeding. This risk can be decreased by scrupulous patient selection, careful control of dosage, and close monitoring. Elderly women and patients with renal failure are more prone to hemorrhage. Heparin is of animal origin and should be used cautiously in patients with allergy. Increased loss of hair and reversible alopecia have been reported. Long-term heparin therapy is associated with osteoporosis and spontaneous fractures. Heparin accelerates the clearing of postprandial lipemia by causing the release of lipoprotein lipase from tissues, and long-term use is associated with mineralocorticoid deficiency.
    • B. Heparin-Induced Thrombocytopenia
    •  
    •  
    • 3. Common type of collagen found in lens is
    • a. Type I
    • b. Type II
    • c. Type III
    • d. Type IV

    • Ans: D, Type IV
    • Please see the picture below.
    • Ref: First Aid for the USMLE 2019 P 50
  29. 29
    • 1. Which of the following neurons do not have acetylcholine as the neurotransmitter?
    • a. Preganglionic sympathetic neurons
    • b. Postganglionic sympathetic neurons
    • c. Preganglionic parasympathetic neurons
    • d. Neurons innervating sweat glands

    • Ans : B. Postganglionic sympathetic neurons
    • Explanation: 
    • ☆Preganglionic neurons :
    • ▪ Sympathetic – acetylcholine
    • ▪ Parasympathetic – acetylcholine
    • ☆Postganglionic neurons :
    • ▪ Sympathetic – norepinephrine
    • ▪ Parasympathetic – acetylcholine
    • Exception: In sympathetic neurons innervating eccrine sweat glands, acetylcholine is the neurotransmitter.

    • 2. Pseudo-isomorphic phenomenon is characteristic of?
    • a. Vitiligo
    • b. Psoriasis
    • c. DLE
    • d. Plane warts

    • Ans : D. Plane warts
    • PSEUDO-ISOMORPHIC PHENOMENON
    • * To learn about pseudo-isomorphic phenomenon, we first need to know what is isomorphic phenomenon.
    • * Isomorphic phenomenon (also known as Koebner phenomenon) is a phenomenon in which new skin lesions appear at the site of injury.
    • * It is named after Heinrich Köbner, a German dermatologist.
    • * Isomorphic phenomenon is seen in conditions like psoriasis, vitiligo and lichen planus.
    • * Pseudo-isomorphic phenomenon (Pseudo-Koebner phenomenon) is characterised by the appearance of similar skin lesions at the site of injury in infective lesions like plane warts and molluscum contagiosum.
    • * It occurs due to the spread of the infective agent (virus) to the new site.

    • 3. All are features of autistic disorders except ?
    • a. Stereotypic movements
    • b. Impairment of social interaction
    • c. Visual impairment
    • d. Delay in speech development
    •  
    • Ans : C. Visual impairment
    • Autistic disorders are characterised by:
    • * Impairement of social interaction
    • * Disorder of communication and language (as in delayed development of speech)
    • * Stereotypic movements
    • Visual impairment is not seen in autism.
  30. 30
    • 1. What is Marjolin’s ulcer?
    • a. Adenocarcinoma
    • b. Basal cell carcinoma
    • c. Melanoma
    • d. Squamous cell carcinoma

    • Ans: d
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 29
    • A chronic ulcer, unresponsive to dressings and simple treatments, should be biopsied to rule out neoplastic change, a squamous cell carcinoma known as a Marjolin’s ulcer being the most common.

    • 2. Which of the following techniques for protein separation is based on charge?
    • a. Affinity chromatography
    • b. size exclusion chromatography
    • c. ion-exchange chromatography
    • d. hydrophobic interaction chromatography

    • Ans: c
    • Ref: Harper Biochemistry 30th Edition, Page No: 26
    • • Highly purified protein is essential for the detailed examination of its physical and functional properties. Cells contain thousands of different proteins, each in widely varying amounts. The isolation of a specific protein in quantities sufficient for analysis of its properties thus presents a formidable challenge that may require successive application of multiple purification techniques. Selective precipitation exploits differences in relative solubility of individual proteins as a function of pH (isoelectric precipitation), polarity (precipitation with ethanol or acetone), or salt concentration (salting out with ammonium sulfate).
    • • Chromatographic techniques separate one protein from another based upon difference in their size (size exclusion chromatography), charge (ion-exchange chromatography), hydrophobicity (hydrophobic interaction chromatography), or ability to bind a specific ligand (affinity chromatography).

    • 3. HACEK group includes all except:
    • a. Hemophilus spp
    • b. Acinetobacter baumannii
    • c. Eikenella corrodens
    • d. Cardiobacterium hominis

    • Ans: b
    • Ref: Surinder Kumar Microbiology, 1st Edition, Page No: 270
    • HACEK group of oral bacteria
    • • (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella spp.).
    • • These organisms are known to colonize endovascular tissue and produce vegetations on heart valves. In common with some other gram-negative rods, such as Cardiobacterium hominis, Eikenella corrodens and Actinobacillus actinomycetemcomitans, Kingella species (usually K. kingae) are sometimes found in endocarditis. They have also been implicated in joint infections.

    • 4. Duhamel’s operation is done in:
    • a. Congenital pyloric stenosis
    • b. Hirschsprung disease
    • c. Achalasia cardia
    • d. Hiatus hernia

    • Ans: b
    • Ref: SRB's Manual of Surgery; 5th Edition, Page No: 888
    • Treatment Hirschsprung disease
    • Initially, colostomy is done either transverse or transitional, so to have normal bowel function.
    • • Nutritional supplementation.
    • • once the child attains 10 kg Weight ,definitive procedure is done, i.e.
    • a) Excision of aganglionic segment (spasmodic segment).
    • b) Maintenance of continuity by doing coloanal anastomosis.
    • c) Closure of colostomy later.

    • Common procedures done are:
    • • Modified Duhamel operation—resection of upper part of the rectum and a part of colon; anastomosis of colon to posterior part of the lower rectum and crushing the spurs to create the rectal pouch. It is technically easier and a retro-rectal pull through. New pouch is created by anterior part of the aganglionic rectum and by ganglionic proximal pulled down colon. Biopsy should be taken from proximal pulled down colon to look for evidence of ganglions. Pulled down proximal colon is sutured to full thickness posterior anal canal just above the dentate line. Spur between these two segments is crushed by Kocher’s forceps or specialized instrument to create a single pouch.
    • • Soave’s mucosectomy and pull through operation.
    • • Coloanal anastomosis after proctocolectomy.
    • • Total proctocolectomy with ileo-anal anastomosis in case of total colonic HD.
    • • Swenson’s operation—through abdomino-anal approach, aganglionic segment is resected and Colo-anal anastomosis is done.
    • • Ano rectal myectomy is found to be very useful for ultra short segment and short-segment Hirschsprung’s disease.

    • 5. Most commonly used Nerve for neurovascular monitoring:
    • a. Medial Nerve
    • b. Axillary Nerve
    • c. Radial Nerve
    • d. Ulnar Nerve

    • Ans: d
    • Ref: Ajay Yadav Anesthesia 4th Edition, Page No: 54
    • Neuromuscular monitoring is required for patients suffering from neuromuscular disease like myasthenia gravis, Duchenne’s muscular dystrophy etc. Most commonly used muscle for neuromuscular monitoring is Adductor Pollicis supplied by Ulnar Nerve.
  31. 31
    • 1. COVID19 is caused by:
    • a. Alpha coronavirus
    • b. Beta coronavirus
    • c. Gamma coronavirus
    • d. Delta coronavirus

    • Ans: b
    • Coronaviruses are enveloped positive-stranded RNA viruses. Full-genome sequencing and phylogenic analysis indicated that the coronavirus that causes COVID-19 is a betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus (as well as several bat coronaviruses), but in a different clade.

    • 2. Risk of transmission of coronavirus is unlikely during which period of infection for otherwise immunocompetent patients with non-severe infection?
    • a. Prior to the development of symptoms
    • b. Early in the course of illness
    • c. 7 to 10 days of illness
    • d. Rate is equal during all above time

    • Ans: c
    • The precise interval during which an individual with SARS-CoV-2 infection can transmit infection to others is uncertain. The potential to transmit SARS-CoV-2 begins prior to the development of symptoms and is highest early in the course of illness; the risk of transmission decreases thereafter. Transmission after 7 to 10 days of illness is unlikely, particularly for otherwise immunocompetent patients with nonsevere infection.

    • 3. Convalescent plasma treatment for COVID-19 provides:
    • a. Antibodies to the pathogen at sufficient titer and provide passive immunity to the recipient
    • b. Antibodies to the pathogen at sufficient titer and provide active immunity to the recipient
    • c. Attenuated antigens to the pathogen at sufficient titer and provide passive immunity to the recipient
    • d. Attenuated antigens to the pathogen at sufficient titer and provide active immunity to the recipient

    • Ans: a
    • Convalescent plasma from individuals who have recovered from COVID-19 may provide clinical benefit to patients with active COVID-19 when given early in the course of disease. The major difference from other plasma products is that convalescent plasma is obtained from donors who have recovered from a specific infection. Ideally, it contains antibodies to the pathogen at sufficient titer and biologic activity to provide passive immunity to the recipient.

    • 4. WHO declared COVID-19 a pandemic in:
    • a. December, 2019
    • b. January, 2020
    • c. February, 2020
    • d. March, 2020

    • Ans: d
    • Coronaviruses are important human and animal pathogens. At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei province of China. It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world. In February 2020, the World Health Organization (WHO) designated the disease COVID-19, which stands for coronavirus disease 2019. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); previously, it was referred to as 2019-nCoV. The WHO declared COVID-19 a pandemic on March 11, 2020.

    • 5. Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 has phenotypic similarity with:
    • a. Kwashiorkor
    • b. Kawasaki disease
    • c. HIV/AIDS
    • d. Meningococcemia

    • Ans: b
    • Distinctions between Multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease
    • There have been increasing reports of a multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 that is similar to Kawasaki disease (KD).
    • Differentiating MIS-C and KD:
    • There is considerable phenotypic overlap with MIS-C and KD. In the available case series, approximately 40 to 50 percent of children with MIS-C met criteria for complete or incomplete KD.
    • However, there appear to be some key differences:
    • • MIS-C commonly affects older children and adolescents, whereas classic KD typically affects infants and young children.
    • • In MIS-C, black and Hispanic children appear to be disproportionally affected, and Asian children account for only a small number of cases. By contrast, classic KD has a higher incidence in East Asia and in children of Asian descent.
    • • Gastrointestinal symptoms (particularly abdominal pain) are very common in MIS-C, whereas these symptoms are less prominent in classic KD.
    • • Myocardial dysfunction and shock occur more commonly in MIS-C compared with classic KD.
    • • Inflammatory markers (especially C-reactive protein, ferritin, and D-dimer) tend to be more elevated in MIS-C compared with KD. In addition, absolute lymphocyte and platelet counts tend to be lower in MIS-C compared with classic KD.
  32. 32
    • 1. The hormone produced by kidney are all except:
    • a. Renin
    • b. Erythropoietin
    • c. Angiotensinogen
    • d. Calcitriol

    • Ans: C
    • Ref: Berne and Levy physiology; 7th edition; Page No: 582
    • • Kidneys are important endocrine organs that produce and secrete renin, calcitriol, and erythropoietin. Renin is not a hormone but an enzyme that activates the renin-angiotensin-aldosterone system, which helps regulate blood pressure and Na+ and K+ balance. Calcitriol, a metabolite of vitamin D3, is necessary for normal absorption of Ca++ by the gastrointestinal tract and for its deposition in bone. In patients with renal disease the kidneys’ ability to produce calcitriol is impaired and levels of this hormone are reduced. As a result, Ca++ absorption by the intestine is decreased, which over time contributes to the bone formation abnormalities seen in patients with chronic renal disease. Another consequence of many kidney diseases is a reduction in erythropoietin production and secretion. Erythropoietin stimulates red blood cell formation by bone marrow. Decreased erythrocyte production contributes to the anemia that occurs in chronic kidney disease (CKD), a progressive loss in kidney function over a period of months or years.

    • 2. Increased depolarization of SA node seen due to:
    • a. Vagus nerve
    • b. Norepinephrine
    • c. Acetylcholine
    • d. Glycine

    • Ans: b
    • Ref: Ganong Review of Medical Physiology, Lange; 25th Edition, Page No: 521
    • Stimulation of the sympathetic cardiac nerves speeds the depolarizing effect of Ih, and the rate of spontaneous discharge increases. Norepinephrine secreted by the sympathetic endings binds to β1 receptors, and the resulting increase in intracellular cAMP facilitates the opening of L channels, increasing ICa and the rapidity of the depolarization phase of the impulse.

    • 3. Which of the following increases gastric HCl secretion?
    • a. Adrenalectomy
    • b. Omeprazole
    • c. Gastric distension
    • d. Duodenal posterior horn less than 4.0

    • Ans: c
    • Ref: Ganong Review of Medical Physiology, Lange; 25th Edition, Page No: 459
    • • However, before the meal enters the stomach, there are few additional triggers and thus the amount of secretion is limited. Once the meal is swallowed, on the other hand, meal constituents trigger substantial release of gastrin and the physical presence of the meal also distends the stomach and activates stretch receptors, which provoke a “vago-vagal” as well as local refl exes that further amplify secretion.
    • • The presence of the meal also buffers gastric acidity that would otherwise serve as a feedback inhibitory signal to shut off secretion secondary to the release of Somatostatin, which inhibits both G and ECL cells as well as secretion by parietal cells themselves. Th is probably represents a key mechanism whereby gastric secretion is terminated after the meal moves from the stomach into the small intestine.

    • 4. Role of vitamin D is:
    • a. Osteoclast activation
    • b. Absorption of calcium
    • c. Bone resorption
    • d. Calcitonin activation

    • Ans: b
    • Ref: Guyton and Hall Textbook of Medical Physiology, Elsevier; 13th Edition, Page No: 1008-1009
    • ACTIONS OF VITAMIN D
    • • Active form of vitamin D, 1,25-dihydroxycholecalciferol, has several effects on the intestines, kidneys, and bones that increase absorption of calcium and phosphate into the extracellular fluid and contribute to feedback regulation of these substances.
    • • Vitamin D receptors are present in most cells in the body and are located mainly in the nuclei of target cells. Similar to receptors for steroids and thyroid hormone, the vitamin D receptor has hormone-binding and DNA binding domains.
    • • The vitamin D receptor forms a complex with another intracellular receptor, the retinoid-X receptor, and this complex binds to DNA and activates transcription in most instances. In some cases, however, vitamin D suppresses transcription.
    • • Although the vitamin D receptor binds several forms of cholecalciferol, its affinity for 1,25-dihydroxycholecalciferol is roughly 1000 times that for 25-hydroxycholecalciferol, which explains their relative biological potencies.

    • 1. “Hormonal” Effect of Vitamin D to Promote Intestinal Calcium Absorption.
    • • 1,25-Dihydroxycholecalciferol functions as a type of “hormone” to promote intestinal absorption of calcium. It promotes this absorption principally by increasing, over a period of about 2 days, formation of calbindin, a calcium-binding protein, in the intestinal epithelial cells. This protein functions in the brush border of these cells to transport calcium into the cell cytoplasm.
    • • The calcium then moves through the basolateral membrane of the cell by facilitated diffusion. The rate of calcium absorption is directly proportional to the quantity of this calcium-binding protein. Furthermore, this protein remains in the cells for several weeks after the 1, 25-dihydroxycholecalciferol has been removed from the body, thus causing a prolonged effect on calcium absorption.
    • Other effects of 1,25-dihydroxycholecalciferol that might play a role in promoting calcium absorption are the formation of
    • • A calcium-stimulated adenosine triphosphatase in the brush border of the epithelial cells and
    • • An alkaline phosphatase in the epithelial cells. The precise details of all these effects are unclear.

    • 2. Vitamin D Promotes Phosphate Absorption by the Intestines.
    • 3. Vitamin D Decreases Renal Calcium and Phosphate Excretion.
  33. 33
    • 1. A 45-year-old man has had progressive dyspnea on exertion with fatigue for the past 2 years. On auscultation of his chest he has a prominent pulmonary component of S2, a systolic murmur of tricuspid insufficiency, and bruits over peripheral lung fields. Jugular venous distension is present to the angle of his jaw when sitting. Laboratory studies show antiphospholipid antibodies. CT angiography shows eccentric occlusions with pulmonary arteries and mosaic attenuation of pulmonary parenchyma. Which of the following is the most likely disease process causing his pulmonary disease?
    • a. Atherosclerosis
    • b. Pneumonitis
    • c. Sarcoidosis
    • d. Thromboembolism

    • Ans: d
    • Ref: Robbins Basis Pathology 9th Edition, Page No: 697–699
    • • Over half of persons with chronic pulmonary thromboembolism with pulmonary hypertension do not have a history of recurrent pulmonary embolism. Rather than one large life-threatening embolus, chronic thromboembolism occurs from multiple smaller emboli that reduce the pulmonary vascular bed and increase pulmonary pressures, leading to cor pulmonale.
    • • Recanalization of thrombi leads to narrow channels causing the bruits. Antiphospholipid anti-bodies pose a risk for thrombosis. The risk factors for systemic arterial atherosclerosis are not operative in the pulmonary arterial tree, and pulmonary atherosclerosis is a consequence of pulmonary hypertension, not a cause of it. Pneumonitis with parenchymal inflammation reduces ventilation more than perfusion.
    • • Sarcoidosis is an idiopathic granulomatous disease that mainly affects the pulmonary parenchyma.

    • 2. ‘Starry sky’ appearance is seen in:
    • a. Burkitt’s lymphoma
    • b. Mantle cell lymphoma
    • c. Extra nodal marginal zone B-cell lymphoma of MALT type
    • d. Chronic myeloid leukemia

    • Ans: a
    • Ref: Robbins Basic Pathology 10th Edition, Page No: 466
    • Burkitt lymphoma:
    • • <1% of lymphomas in the United States
    • • Morphology: Intermediate-sized cells with several nucleoli; diffuse growth pattern; frequent apoptotic cells (“starry sky” appearance)
    • • Cell of origin: Germinal center B cell
    • • Associated with t(8;14) and EBV (subset); highly aggressive

    • 3. What is myelin figures derived from?
    • a. Cellular membrane
    • b. Chromatins
    • c. Lysosomes
    • d. Mitochondria

    • Ans: a
    • Ref: Robbins Basic Pathology 10th Edition, Page No: 33
    • • The two main morphologic correlates of reversible cell injury are cellular swelling and fatty change.
    • • Cellular swelling is commonly seen in cell injury associated with increased permeability of the plasma membrane. It may be difficult to appreciate with the light microscope, but it is often apparent at the level of the whole organ. When it affects many cells in an organ, it causes pallor (as a result of compression of capillaries), increased turgor, and an increase in organ weight. Microscopic examination may show small, clear vacuoles within the cytoplasm; these represent distended and pinched-off segments of the endoplasmic reticulum (ER).This pattern of nonlethal injury is sometimes called hydropic change or vacuolar degeneration.
    • • Fatty change is manifested by the appearance of triglyceride containing lipid vacuoles in the cytoplasm. It is principally encountered in organs that are involved in lipid metabolism, such as the liver.
    • • The cytoplasm of injured cells also may become redder (eosinophilic), a change that becomes much more pronounced with progression to necrosis (described later). Other intracellular changes associated with cell injury include (1) plasma membrane alterations such as blebbing, blunting, or distortion of microvilli, and loosening of intercellular attachments; (2) mitochondrial changes such as swelling and the appearance of phospholipid-rich amorphous densities; (3) dilation of the ER with detachment of ribosomes and dissociation of polysomes; and (4) nuclear alterations, such as clumping of chromatin.
    • • The cytoplasm may contain so-called “myelin figures,” which are collections of phospholipids resembling myelin sheaths that are derived from damaged cellular membranes.


    • 4. A 14-year-old girl noticed gradual neck enlargement during the past 8 months. On physical examination her thyroid gland is diffusely enlarged. Her serum TSH level is normal. A dietary history is most likely to reveal that she has begun eating more of which of the following foods?
    • a. Cabbage
    • b. Fava beans
    • c. Fish
    • d. Rye bread

    • Ans: a
    • Ref: Robbins Basis Pathology 9th Edition, Page No: 1091
    • • She has developed a sporadic goiter. Vegetables of the Brassicaceae family, including cabbage, turnips, and Brussels sprouts, contain glucosinolates, which can decompose to release thiocyanate, a byproduct that interferes with thyroid hormone synthesis. Thus such substances are known as goitrogens. Young persons with increased demand for thyroid hormone are at increased risk.
    • • Fava beans contain oxidizing agents that incite hemolysis in persons with glucose- 6-phosphate dehydrogenase (G6PD) deficiency. In addition, beans contain long-chain sugars that are indigestible with human intestinal enzymes, leaving them to be fermented by colonic bacteria that release gas (flatus).
    • • Fish have omega-3 fatty acids that protect against atherogenesis.
    • • Fungus growing on moldy rye produces ergot poisoning.
  34. 34
    • 1. Einthoven’s triangle, what is the value of Lead III when Lead I = 2 mV and Lead II = 1 mV?
    • a. 1
    • b. 2
    • c. 3
    • d. 4

    • Ans: a
    • Ref: Guyton and Hall Textbook of Medical Physiology, Elsevier; 13th Edition, Page No: 135
    • Einthoven’s Law
    • Einthoven’s law states that if the ECGs are recorded simultaneously with the three limb leads, the sum of the potentials recorded in leads I and III will equal the potential in lead II.
    • Lead I potential + Lead III potential = Lead II potential

    • 2. The timing of fine crackles that is heard in interstitial lung disease is
    • a. End inspiratory
    • b. Early inspiratory
    • c. Early expiratory
    • d. End expiratory

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 2001
    • • End-inspiratory fine crackles, or rales, noted at the lung bases are found in most patients with IPF and may be one of the earliest signs of the disease. However, rales are nonspecific and can be found in many forms of ILD and other disorders.
    • • Wheezing is uncommon in most forms of ILD but can be present in some disorders, such as sarcoidosis, HP, and eosinophilic GPA. Signs of advanced disease include cyanosis, digital clubbing, and cor pulmonale.

    • 3. 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.

    • 4. CSF otorrhea is caused by:
    • a. Fracture of cribriform plate
    • b. Fracture of parietal bone
    • c. Fracture of petrous temporal bone
    • d. Fracture of tympanic membrane

    • Ans: c
    • Ref: Gautam Biswas Forensic Medicine, 3rdEdition, Page No: 236
    • Fracture of middle cranial fossa:
    • It is seen due to direct impact behind the ear or crush injuries of the head. It manifests by CSF otorrhea if petrous part of temporal bone is fractured (or rhinorrhea via Eustachian tube), hemotympanum, ossicular disruption, Battle sign, or VII and VIII nerve palsy.
  35. 35
    • 1. Coxsackie virus is:
    • a. Herpes virus
    • b. Pox virus
    • c. Enterovirus
    • d. Myxovirus

    • Ans: c
    • Ref: Jawetz Microbiology 26th Edition, Page No: 866
    • Picornaviridae
    • Enterovirus
    • • Coxsackie A viruses
    • • Coxsackie B viruses
    • • Echoviruses
    • • Enteroviruses
    • • Polioviruses
    • Hepatovirus
    • • Hepatitis A virus
    • Parechovirus
    • • Parechoviruses
    • Rhinovirus
    • • Common cold viruses

    • 2. What is to be corrected first in neonatal resuscitation?
    • a. Airway
    • b. Breathing
    • c. Circulation
    • d. Temperature

    • Ans: d
    • Ref: OP Ghai Pediatrics 9th Edition, Page No: 127 – 128
    • The components of the neonatal resuscitation can be summarized as TABC:
    •  T-Temperature: Provide warmth, dry the baby and remove the wet linen.
    •  A-Airway: Position the infant, clear the airway, if required(by wiping or suction of baby's mouth and nose). Ifnecessary, insert an endotracheal tube to ensure an open airway.
    •  B-Breathing: Tactile stimulation to initiate respirations, positive-pressure breaths using either bag and mask or bag and ET tube as necessary.
    •  C-Circulation: Stimulate and maintain the circulation of blood with chest compressions and medications as indicated.

    • 3. Most common causative organisms for lung abscess is?
    • a. Anaerobic bacteria
    • b. S. aureus
    • c. Klebsiella pneumoniae
    • d. M. tuberculosis

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 813
    • • Lung abscesses are usually characterized as either primary (~80% of cases) or secondary. Primary lung abscesses usually arise from aspiration, are often caused principally by anaerobic bacteria, and occur in the absence of an underlying pulmonary or systemic condition.
    • • Secondary lung abscesses arise in the setting of an underlying condition, such as a postobstructive process (e.g., a bronchial foreign body or tumor) or a systemic process (e.g., HIV infection or another immunocompromising condition). Lung abscesses can also be characterized as acute (<4–6 weeks in duration) or chronic (~40% of cases).

    • 4. Estimation of which of the following helps to distinguish between organic and psychogenic seizures?
    • a. Serum insulin levels
    • b. Serum growth hormone levels
    • c. Serum prolactin levels
    • d. Serum vasopressin levels

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2551
    • Most generalized seizures and many complex partial seizures are accompanied by rises in serum prolactin during the immediate 30 minute postictal period, whereas psychogenic seizures are not. Peripheral WBC count also increase significantly after a generalized seizure.
  36. 36
    • 1. CT value in RT-PCR means:
    • a. Computed tomogram
    • b. Cycle threshold
    • c. Closed theory
    • d. Continuous take off

    • Ans: b
    • In a real time PCR assay a positive reaction is detected by accumulation of a fluorescent signal. The CT (cycle threshold) is defined as the number of cycles required for the fluorescent signal to cross the threshold (ie exceeds background level).

    • 2. Which nerve stimulation has been used to treat medically intractable seizure?
    • a. Olfactory nerve
    • b. Vestibulocochlear nerve
    • c. Glossopharyngeal nerve
    • d. Vagus nerve

    • Ans: d
    • Vagus nerve stimulation (VNS) has been approved for adjunctive treatment of medically intractable partial onset seizures in adults and children over 12 years of age. Approximately 30 to 40 percent of patients achieve a greater than 50 percent reduction in seizure frequency, a benefit that is sustained over time. Serious adverse events are rare.
    • Reference: Uptodate

    • 3. Side effect of topiramate:
    • a. Visual impairment
    • b. Insomnia
    • c. Hemolysis
    • d. Weight loss

    • Ans: d
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 7th Edition, Page No: 420
    • Topiramate
    • • This weak carbonic anhydrase inhibitor has broad spectrum anticonvulsant activity in maximal electroshock, PTZ induced clonic seizures and in kindling model. It appears to act by multiple mechanisms, viz phenytoin like prolongation of Na+ channel inactivation, GABA potentiation by a postsynaptic effect, antagonism of certain glutamate receptors and neuronal hyperpolarization through certain K+ channels.
    • • Topiramate is indicated as monotherapy as well as for supplementing primary antiepileptic drug in refractory SPS, CPS and GTCS. Promising results have been obtained in myoclonic epilepsy. Topiramate is readily absorbed orally and mainly excreted unchanged in urine with an average t1⁄2 of 24 hours.
    • • Adverse effects are impairment of attention, sedation, and ataxia, word finding difficulties, poor memory, weight loss, paresthesias and renal stones.
    • • Recently, topiramate has been approved for prophylaxis of migraine; may be used when β blockers/other prophylactics are contraindicated or are not effective.

    • 4. At birth the ovary contains primary oocyte in which stage of meiosis?
    • a. Prophase I
    • b. Metaphase
    • c. Anaphase
    • d. Telophase I

    • Ans: A
    • Ref: TW Sadler Embryology, Langman’s, 13th Edition, Page No: 27
    • • In the ovaries, primary oocytes reach diplotene stage of prophase I (meiosis I), by the fifth month in utero and each remains at this stage until the period before ovulation (may be as long as up to 50 years).
  37. 37
    • 1. Pain is often absent in pericarditis when the etiology is
    • a. Uremia
    • b. Dressler syndrome
    • c. Viral
    • d. SLE

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1841
    • • Chest pain is usually present in acute infectious pericarditis and in many of the forms presumed to be related to hypersensitivity, autoimmunity, or of unknown cause (idiopathic).
    • • The pain of acute pericarditis is often severe, retrosternal and/or left precordial, and referred to the neck, arms, or left shoulder. Frequently the pain is pleuritic, consequent to accompanying pleural inflammation (i.e., sharp and aggravated by inspiration and coughing), but sometimes it is steady, radiates to the trapezius ridge, or into either arm, and resembles that of myocardial ischemia; therefore, confusion with acute myocardial infarction (AMI) is common.
    • • Characteristically, pericardial pain may be intensified by lying supine, and relieved by sitting up and leaning forward.
    • • Pain is often absent in slowly developing tuberculous, postirradiation, neoplastic, and uremic pericarditis.

    • 2. What is the formula of Vital capacity
    • a. Tidal volume + IRV
    • b. Tidal volume + ERV
    • c. Inspiratory capacity + ERV
    • d. ERV+RV

    • Ans: c
    • Ref: Guyton and Hall Textbook of Medical Physiology, Elsevier; 13th Edition, Page No: 502
    • The vital capacity equals the inspiratory reserve volume plus the tidal volume plus the expiratory reserve volume. This capacity is the maximum amount of air a person can expel from the lungs after first filling the lungs to their maximum extent and then expiring to the maximum extent (about 4600 milliliters

    • VC = IRV + VT (Tidal volume) + ERV
    • VC = IC + ERV
    • because [IRV + VT (Tidal volume) = IC]

    • 3. Excessive buying is termed as:
    • a. Kleptomania
    • b. Oniomania
    • c. Trichotillomania
    • d. Pyromania

    • Ans: b
    • Ref: Gautam Biswas Forensic Medicine, 3rdEdition, Page No: 405
    •  Kleptomania: Pathological compulsion to steal articles which may be of little value and may not even be useful to the person.
    •  Dipsomania: Compulsion to drink alcoholic beverages.
    •  Pyromania: Irresistible desire to set things on fire which is characterized by two or more acts of fire setting without apparent motive.
    •  Mutilomania: Irresistible desire to injure and mutilate animals, commonly domestic pets.
    •  Oniomania: Compulsive desire to shop (shopping addiction).
    •  Trichotillomania: Noticeable hair loss caused by person’s persistent and recurrent failure to resist impulses to pullout hair.
    •  Suicidal impulse: Often intoxication (e.g. LSD) may lead to suicidal impulse.
    •  Homicidal impulse: With certain chronic intoxications, e.g. cannabis, a man may go on a sudden killing spree.

    • 4. All of the following are branches of cavernous part of internal carotid artery except:
    • a. Cavernous artery
    • b. Pterygoid artery
    • c. Hypophyseal artery
    • d. Meningeal artery

    • Ans: b
    • Ref: Gray’s anatomy, 41st Edition; Page No: 280-281
    • Branches from different parts of internal carotid artery
    • Cervical part
    • No branch
    • Petrous part
    • • Caroticotympanic artery
    • • Pterygoid artery
    • Cavernous part
    • • Cavernous artery
    • • Hypophyseal artery
    • • Meningeal artery
    • Cerebral artery
    • • Anterior cerebral artery
    • • Middle cerebral artery
    • • Ophthalmic artery
    • • Posterior communicating artery
    • • Anterior choroidal artery


    • Answer to Off the Topic Question of Teej:
    • In Hartitalika Teej, literal meaning of Haritalika is:
    • a. Purity and sacrifice
    • b. Fasting without water
    • c. Abduction of female friend
    • d. Long life of husband

    • Ans: c
    • Hartalika is a combination of the Hindi words harit and aalika which means "abduction" and "female friend" respectively. According to the legend of Hartalika Teej, Parvati, incarnated as Shailaputri, was the daughter of Himavat who promised her hand in marriage to Vishnu, at the suggestion of Narada. Upon hearing this, Parvati told her friend of her father's decision whereupon the friend took Parvati to the thick forest so that her father would not marry her to Vishnu against her wish.
  38. 38
    • 1. Severe muscle weakness is seen in?
    • a. Cori disease
    • b. Andersen disease
    • c. McArdle disease
    • d. Tarui disease

    • Ans: B. Andersen disease
    • Ref: Davidson’s Principles and Practice of Medicine, 22nd edition, p450
    • Glycogen storage disease – liver biopsy
    • * Andersen disease is a type 4 glycogen storage disease.
    • * It occurs due to deficiency of brancher enzyme.
    • * It usually presents in infancy with severe muscle weakness.
    • * Cirrhosis can also occur.

    • 2. Which of the following congenital malformations can be diagnosed in the first trimester ?
    • a. Microcephaly
    • b. Anencephaly
    • c. Meningocele
    • d. Encephalocele

    • Ans: B. Anencephaly
    • CONGENITAL MALFORMATIONS DIAGNOSED IN THE FIRST TRIMESTER
    • * Routine ultrasound scan for the diagnosis of congenital anomalies is done in the second trimester
    • * But in high risk cases, an early anomaly scan is done to identify major anomalies
    • * The congenital anomalies that can be identified in the first trimester are:
    • * Acrania – Condition in which the flat bones of the cranial vault are partially or completely absent. It is an early stage of anencephaly.
    • * Exencephaly – An early stage of anencephaly in which the brain is located outside the skull
    • * Anencephaly – Absence of a major part of the brain, skull and scalp. It is an anomaly that occurs when the rostral end of the neural tube fails to close.

    • 3. In which one of the following head and neck cancer, perineural invasion is most commonly seen?
    • a. Adenocarcinoma
    • b. Adenoid cystic carcinoma
    • c. Basal Cell Adenoma
    • d. Squamous cell carcinoma

    • Ans: B. Adenoid cystic carcinoma
    • Perineural invasion is characteristically seen in adenoid cystic carcinoma. It is the most common malignant tumour of submandibular salivary glands.

    • 4. Which of the following contrast agents can be used in a patient with renal dysfunction for the prevention of contrast nephropathy?
    • a. Low osmolar contrast
    • b. Ionic contrast
    • c. Fenoldopam
    • d. Acetylcysteine

    • Ans: A. Low osmolar contrast
    • PREVENTION OF CONTRAST NEPHROPATHY
    • * Non ionic low osmolar contrast agents are preferred in patients with decreased renal function to prevent contrast nephropathy
    • * Ionic contrast media have a higher risk for contrast nephropathy, and hence should be avoided
    • * The amount of contrast media used should be limited
    • * The patient should be well hydrated before the procedure
    • * Supplementary interventions include use of N-acetylcysteine, fenoldopam, theophylline, prostaglandins and magnesium
  39. 39
    • 1. Café-au-lait spots are seen in:
    • a. NF1
    • b. NF2
    • c. NF3
    • d. NF4

    Ans: a

    • 2. In developmental milestone, imaginative play is seen by:
    • a. 19 months
    • b. 24 months
    • c. 30 months
    • d. 36 months

    Ans: d

    • 3. Quadriplegia may result from spinal cord transection at:
    • a. C1–C3
    • b. C4–C5
    • c. C6–C8
    • d. T1–T9


    Ans: b

    • 4. GS-441524 is an antiviral drug and main plasma metabolite of:
    • a. Indinavir
    • b. Remdesivir
    • c. Didanosine
    • d. Azathioprine

    Ans: b

    • 5. Enzymatic marker of inner mitochondrial membrane is:
    • a. Na K ATPase
    • b. Galactosyl transferase
    • c. Nucleotidase
    • d. ATP synthase

    Ans: d
  40. 40
    • 1. Spatial relationship between various types of polypeptides in protein is depicted by:
    • a. Primary structure
    • b. Secondary structure
    • c. Tertiary structure
    • d. Quaternary structure

    • Ans: d
    • Ref: Harper Biochemistry 30th Edition, Page No: 47
    • • Proteins may be classified based on their solubility, shape, or function or on the presence of a prosthetic group, such as heme.
    • • The gene-encoded primary structure of a polypeptide is the sequence of its amino acids. Its secondary structure results from folding of polypeptides into hydrogen-bonded motifs such as the a helix, the β pleated sheet, β bends, and loops.
    • • Combinations of these motifs can form supersecondary motifs.
    • • Tertiary structure concerns the relationships between secondary structural domains. Quaternary structure of proteins with two or more polypeptides (oligomeric proteins) concerns the spatial relationships between various types of polypeptides.
    • • Primary structures are stabilized by covalent peptide bonds. Higher orders of structure are stabilized by weak forces— multiple hydrogen bonds, salt (electrostatic) bonds, and association of hydrophobic R groups.

    • 2. Acetyl-CoA carboxylase converts:
    • a. Acetyl-CoA to mevalonate
    • b. Mevalonate to Acetyl-CoA
    • c. Acetyl-CoA to malonyl-CoA
    • d. Malonyl-CoA to Acetyl-CoA

    • Ans: c
    • Ref: Harper Biochemistry 30th Edition, Page No: 243
    • Acetyl-CoA carboxylase converts acetyl-CoA to malonyl-CoA, and then fatty acid synthase, a multienzyme complex consisting of two identical polypeptide chains, each containing six separate enzymatic activities and ACP, catalyzes the formation of palmitate from one acetyl-CoA and seven malonyl-CoA molecules.

    • 3. Thymine is produced by deamination of:
    • a. Cytosine
    • b. Adenine
    • c. Guanine
    • d. 5-methylcytosine

    • Ans: d
    • Ref: USMLE Step 1 First Aid 2020, Page No: 35
    • Deamination reactions:
    • • Cytosine: Uracil
    • • Adenine: Hypoxanthine
    • • Guanine: Xanthine
    • • 5-methylcytosine: Thymine

    • 4. CTG trinucleotide repeat expansion disease is:
    • a. Huntington disease
    • b. Myotonic dystrophy
    • c. Fragile X syndrome
    • d. Friedreich ataxia

    • Ans: b
    • Ref: USMLE Step 1 First Aid 2020, Page No: 62
    • Trinucleotide repeat expansion diseases
    • • Huntington disease (CAG)n
    • • Myotonic dystrophy (CTG)n
    • • Fragile X syndrome (CGG)n
    • • Friedreich ataxia (GAA)n
  41. 41
    Answers & Winners of QUIZ ON MANDATORY CPD TOPICS

    • 1. You suspect a head and neck injury in a victim who is unresponsive and not breathing. How would you open the airway to give breaths?
    • a. Thumb & index lift
    • b. E-C clamp technique
    • c. Jaw-thrust technique
    • d. Head tilt-chin lift

    • Ans: c
    • Jaw-thrust technique
    • It is performed by placing the index and middle fingers to physically push the posterior aspects of the lower jaw upwards while their thumbs push down on the chin to open the mouth. When the mandible is displaced forward, it pulls the tongue forward and prevents it from obstructing the entrance to the trachea.

    • Head tilt-chin lift
    • The maneuver is performed by tilting the head backwards in unconscious patients, often by applying pressure to the forehead and the chin. The maneuver is used in any patient in whom cervical spine injury is not a concern and is taught on most first aid courses as the standard way of clearing an airway.

    • 2. Heinrich’s safety pyramid is:
    • a. Unsafe acts or near misses lead to minor injuries and, over time, to a major injury
    • b. Patient safety is more prioritized than health care worker safety
    • c. Health care worker safety is more prioritized than patient safety
    • d. Auditing of patient risk factors

    • Ans: a
    • Heinrich’s safety pyramid
    • • Developed in 1931, Heinrich’s safety pyramid theorised that unsafe acts or near misses lead to minor injuries and, over time, to a major injury. The accident pyramid proposes that for every 300 near misses there are 29 minor injuries and one major injury.
    • • Risk assessment, which is a step in risk management that calculates the value of risk related to a situation or hazard, has shown us that what prevents patients from being hurt is not only by reducing the number of mistakes but rather by increasing the number of defences set up against the consequences of mistakes.
    • • The key message is that near misses provide the best data about the reliability of safety systems. It is, therefore, most important to report near misses as well as adverse events to ensure that defences against adverse events are built and sustained.

    • 3. Washing hands with soap and water could reduce diarrheal disease-associated deaths by up to:
    • a. 20 %
    • b. 50 %
    • c. 90 %
    • d. 100 %

    • Ans: b
    • Ref: CDC website
    •  It is estimated that washing hands with soap and water could reduce diarrheal disease-associated deaths by up to 50%.
    •  A large percentage of foodborne disease outbreaks are spread by contaminated hands.
    •  Appropriate hand washing practices can reduce the risk of foodborne illness and other infections.
    •  Handwashing can reduce the risk of respiratory infections by 16%.

    • 4. Handling of viral specimen of SARS CoV2 requires biosafety level of:
    • a. BSL-1
    • b. BSL-2
    • c. BSL-3
    • d. BSL-4

    • Ans: b
    • Ref: CDC website
    • Routine diagnostic testing of specimens, such as the following activities, can be handled in a BSL-2 laboratory using Standard Precautions:
    •  Using automated instruments and analyzers
    •  Processing initial samples
    •  Staining and microscopic analysis of fixed smears
    •  Examination of bacterial cultures
    •  Pathologic examination and processing of formalin-fixed or otherwise inactivated tissues
    •  Molecular analysis of extracted nucleic acid preparations
    •  Final packaging of specimens for transport to diagnostic laboratories for additional testing (specimens should already be in a sealed, decontaminated primary container)
    •  Using inactivated specimens, such as specimens in nucleic acid extraction buffer
    •  Performing electron microscopic studies with glutaraldehyde-fixed grids

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Prabin Poudel
    • - Dr Pragya Sharma

    • Lucky draw winners:
    • - Dr Raju Gupta
    • - Dr Srijana Rawal

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Subject-wise (Biochemistry and CPD Topics) Based Model test of Bhadra 8 (Monday, 07:00 PM).
  42. 42
    Answers and Winners of QUIZ for Today evening CEE MD/MS Based Online Model Test [07:00 PM, Bhadra 10, Wednesday]

    • 1. How do you know the victim is receiving adequate breaths during CPR?
    • a. The victim's chest rises
    • b. The victim's stomach rises
    • c. There is no definite way to tell without medical intervention
    • d. The victim's chin begins to move forward

    • Ans: a
    • To perform the mouth-to-mouth technique, the provider does the following:
    •  Pinch the patient’s nostrils closed to assist with an airtight seal
    •  Put the mouth completely over the patient’s mouth
    •  After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
    •  Give each breath for approximately 1 second with enough force to make the patient’s chest rise
    •  Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion
    •  After giving the 2 breaths, resume the CPR cycle

    • 2. Group A bioterrorism includes:
    • a. B anthracis
    • b. M. Lepra
    • c. SARS
    • d. Nipah

    • Ans: a
    • Ref: Centre for Disease Control and Prevention website
    • Bioterrorism Agents/Diseases
    • Category A
    •  Anthrax (Bacillus anthracis)
    •  Botulism (Clostridium botulinum toxin)
    •  Plague (Yersinia pestis)
    •  Smallpox (variola major)
    •  Tularemia (Francisella tularensis)
    •  Viral hemorrhagic fevers, including
    •  Filoviruses (Ebola, Marburg)
    •  Arenaviruses (Lassa, Machupo)
    • Category B
    •  Brucellosis (Brucella species)
    •  Epsilon toxin of Clostridium perfringens
    •  Food safety threats (Salmonella species, Escherichia coli O157:H7, Shigella)
    •  Glanders (Burkholderia mallei)
    •  Melioidosis (Burkholderia pseudomallei)
    •  Psittacosis (Chlamydia psittaci)
    •  Q fever (Coxiella burnetii)
    •  Ricin toxin from Ricinus communis (castor beans)
    •  Staphylococcal enterotoxin B
    •  Typhus fever (Rickettsia prowazekii)
    •  Viral encephalitis (alphaviruses, such as eastern equine encephalitis, Venezuelan equine encephalitis, and western equine encephalitis])
    •  Water safety threats (Vibrio cholerae, Cryptosporidium parvum)
    • Category C
    •  Emerging infectious diseases such as Nipah virus and hantavirus

    • 3. Current recommendations state that a single hemoglobin A1c value of greater than 6.5% is diagnostic of diabetes mellitus. If this 6.5% cut-off is to be increased to 7.0%, which of the following would be true?
    • a. Increase in false negative test results
    • b. Increase in false positive test results
    • c. Decrease in true negative test results
    • d. Increase in true positive test results

    • Ans: a
    • An increase in the cut-off value of a test leads to an increase in the number of false negatives. In other words, the higher the threshold for diagnosis, the more individuals who actually have diabetes mellitus there will be who falsely test negative for the disease.
    •  For the majority of diagnostic tests, where results are reported on a continuous scale, the test result distributions of both patients with disease and patients without disease overlap. Any cut-off level requires a certain balance between the false positive rate (causing healthy patients to undergo unnecessary further testing and/or treatment) versus the false negative rate (causing patients with the disease to go undiagnosed and untreated). Note that a gold standard for identifying diseased versus normal patients is necessary for a cut-off point to function appropriately.
    •  Increasing the cut-off point of a test is associated with a decrease in false positive test results.
    •  Increasing the cut-off point of a test is associated with an increase in true negative test results.
    •  Increasing the cut-off point of a test is associated with a decrease in true positive test results.
    •  Increasing the cut-off point of a test leads to an increase in test specificity and a decrease in sensitivity.

    • 4. TB regimens categories in Nepal are:
    • a. New and Old
    • b. Drug susceptible and resistant
    • c. Mild and severe
    • d. Pulmonary and Extra-pulmonary

    • Ans: b
    • Source: National Tuberculosis Centre, 2019
    • Tuberculosis treatment Regimen Update:
    • Two treatment regimens available only:
    • - Drug susceptible TB regimen: 2HRZE + 4HR
    • - Drug resistant TB regimen
    • Any patient coming for re-treatment: Drug susceptibility test performed (Genxpert MTB/RIF):
    • Rifampicin Resistant: Send to DR center for treatment
    • Rifampicin sensitive: Isoniazid sensitivity test (Line probe assay/LPA).
    • - If Isoniazid resistant: 6HRZELfx
    • - If Isoniazid sensitive: 2HRZE + 4HR
    • - If LPA test is not available, Consider Rifampicin sensitive, Isoniazid unknown: 6HRZE

    CNS TB, TB Pericarditis, Musculoskeletal TB, Miliary TB: 2HRZE + 7 HRE
  43. 43
    • Congratulations to the winners of last quiz.
    • Correct ans: BBBA

    • 1. Severe muscle weakness is seen in?
    • a. Cori disease
    • b. Andersen disease
    • c. McArdle disease
    • d. Tarui disease

    • Ans: B. Andersen disease
    • Ref: Davidson’s Principles and Practice of Medicine, 22nd edition, p450
    • Glycogen storage disease – liver biopsy
    • * Andersen disease is a type 4 glycogen storage disease.
    • * It occurs due to deficiency of brancher enzyme.
    • * It usually presents in infancy with severe muscle weakness.
    • * Cirrhosis can also occur.

    • 2. Which of the following congenital malformations can be diagnosed in the first trimester ?
    • a. Microcephaly
    • b. Anencephaly
    • c. Meningocele
    • d. Encephalocele

    • Ans: B. Anencephaly
    • CONGENITAL MALFORMATIONS DIAGNOSED IN THE FIRST TRIMESTER
    • * Routine ultrasound scan for the diagnosis of congenital anomalies is done in the second trimester
    • * But in high risk cases, an early anomaly scan is done to identify major anomalies
    • * The congenital anomalies that can be identified in the first trimester are:
    • * Acrania – Condition in which the flat bones of the cranial vault are partially or completely absent. It is an early stage of anencephaly.
    • * Exencephaly – An early stage of anencephaly in which the brain is located outside the skull
    • * Anencephaly – Absence of a major part of the brain, skull and scalp. It is an anomaly that occurs when the rostral end of the neural tube fails to close.

    • 3. In which one of the following head and neck cancer, perineural invasion is most commonly seen?
    • a. Adenocarcinoma
    • b. Adenoid cystic carcinoma
    • c. Basal Cell Adenoma
    • d. Squamous cell carcinoma

    • Ans: B. Adenoid cystic carcinoma
    • Perineural invasion is characteristically seen in adenoid cystic carcinoma. It is the most common malignant tumour of submandibular salivary glands.

    • 4. Which of the following contrast agents can be used in a patient with renal dysfunction for the prevention of contrast nephropathy?
    • a. Low osmolar contrast
    • b. Ionic contrast
    • c. Fenoldopam
    • d. Acetylcysteine

    • Ans: A. Low osmolar contrast
    • PREVENTION OF CONTRAST NEPHROPATHY
    • * Non ionic low osmolar contrast agents are preferred in patients with decreased renal function to prevent contrast nephropathy
    • * Ionic contrast media have a higher risk for contrast nephropathy, and hence should be avoided
    • * The amount of contrast media used should be limited
    • * The patient should be well hydrated before the procedure
    • * Supplementary interventions include use of N-acetylcysteine, fenoldopam, theophylline, prostaglandins and magnesium
  44. 44
    • Bankart’s lesion is seen in: (AI 2016)
    • A. Recurrent anterior shoulder dislocation
    • B. Posterior shoulder dislocation
    • C. Rotator cuff tear
    • D. Interior shoulder dislocation
    • Ans. is ‘A’ Recurrent anterior shoulder dislocation

    • 2. What is the normal orientation of humeral head:
    • (CET July 16)
    • A. Retroversion of 80 degrees B. Retroversion of 30 degrees
    • C. Anteversion of 15 degrees D. Anteversion of 50 degrees
    • Ans. is ‘B’ Retroversion of 30 degrees

    • 1. Shoulder dislocation false is: (AI 2016)
    • A. Most common early complication of anterior dislocation shoulder is nerve injury
    • B. Hill Sachs is seen in recurrent anterior shoulder dislo￾cation
    • C. Rotator cuff injury is a common cause of recurrent
    • dislocation
    • D. Posterior dislocation presents with difficulty in external rotation of shoulder
    • E. Recurrent dislocation is most commonly seen in shoulder
    • joint
    • Ans. is ‘C’ Rotator cuff injury is a common cause of recurrent
    • dislocation

    • 2. Putti Platt’s operation involves tightening of which muscle: (AI 2016)
    • A. Supraspinatus B. Subscapularis C. Infraspinatus D. Deltoid
    • Ans. is ‘B’ Subscapularis

    • 3. Which of the following is true about anterior shoulder
    • dislocation:- (CET July 16)
    • A. It is most common type of shoulder dislocation
    • B. It is most commonly subclavicular
    • C. Patient keeps his arm in saluting position
    • D. Injury to brachial plexus may occur
    • Ans. is ‘A’ It is most common type of shoulder dislocation

    • 4. Hamilton Ruler test sign is positive in which of the above
    • mentioned conditions? (AI Dec 15)
    • A. Anterior dislocation of shoulder
    • B. Acromioclavivular joint dislocation
    • C. Posterior dislocation of shoulder
    • D. Luxatio erecta
    • Ans. is ‘A’ Anterior dislocation of shoulder

    • Following Defect (lesion) is NOT responsible for recurrent
    • anterior dislocation of shoulder: (Maharashtra PG 2016)
    • A. Bankart's lesion
    • B. Hill-Sachs lesion
    • C. Bristow's lesion
    • D. A defect in the anterior-inferior capsule
    • Ans. is ‘C’ Bristow's lesion

    • Putti Plat operation is done for: (NEET 2015)
    • A. Elbow instability B. Shoulder instability C. Rotator cuff tear D. Biceps tendinitis
    • Ans. is ‘B’ Shoulder instability

    • 7. All are seen in anterior shoulder dislocation except:
    • A. Elevated anterior axillary fold (TN 2014)
    • B. Duga's positive
    • C. Hamilton Ruler positive
    • D. Increased vertical circumference
    • Ans. ‘A' Elevated anterior axillary fold
  45. 45
    • 1. Least common type of twins:
    • a. Diamniotic dichorionic twins
    • b. Diamniotic monochorionic twins
    • c. Monoamniotic monochorionic twins
    • d. Conjoined twins

    • Ans: d
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 200
    • Dizygotic twins: 80%
    • Monozygotic twins: 20%
    •  Diamniotic dichorionic 30%
    •  Diamniotic monochorionic 66%
    •  Monoamniotic monochorionic 3%
    •  Conjoined twins or Siamese twin <3%

    • 2. If community transmission of SARS-CoV-2 is present, residents should be encouraged to practice social distancing by avoiding crowds and maintaining a distance of at least:
    • a. 1 foot
    • b. 2 feet
    • c. 3 feet
    • d. 4 feet

    • Ans: c
    • If community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is present, residents should be encouraged to practice social distancing by avoiding crowds and maintaining a distance of six feet (two meters) from others when in public. In particular, individuals should avoid close contact with ill individuals. Individuals are also encouraged to wear masks when out in public.
    • The optimal distance is uncertain; in the United States, the CDC recommends a minimum distance of six feet (two meters), whereas the WHO recommends a minimum distance of three feet (one meter).

    • The following general measures are additionally recommended to reduce transmission of infection:
    •  Diligent hand washing, particularly after touching surfaces in public. Use of hand sanitizer that contains at least 60 percent alcohol is a reasonable alternative if the hands are not visibly dirty.
    •  Respiratory hygiene (eg, covering the cough or sneeze).
    •  Avoiding touching the face (in particular eyes, nose, and mouth). The American Academy of Ophthalmology suggests that people not wear contact lenses, because they make people touch their eyes more frequently.
    •  Cleaning and disinfecting objects and surfaces that are frequently touched.
    •  Ensure adequate ventilation of indoor spaces.

    • 3. Sewage is:
    • a. Waste water with solid excreta
    • b. Waste water with liquid excreta
    • c. Waste water with solid and liquid excreta
    • d. Waste water without human excreta

    • Ans: c
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 762
    • Sewage is waste water from a community, containing solid and liquid excreta, derived from houses, street and yard washings, factories and industries. It resembles dirty water with an unpleasant smell. The term "sullage" is applied to waste water which does not contain human excreta, e.g., waste water from kitchens and bathrooms.

    • 4. A sexually active male presented with urethral discharge. Gram stain showed intracellular gram negative organisms suggestive of Neisseria gonorrhoeae. Which component produced by the organism is responsible for attachment to host cells?
    • a. Lipooligosaccharide
    • b. Pili
    • c. Outer membrane protein
    • d. IgA1 protease

    • Ans: b
    • Ref: Jawetz’s Medical Microbiology; Lange; 27th Edition, Page No: 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.
  46. 46
    • 1. Which of the following autoimmune disease is associated with a highly specific autoantibody directed against aquaporin-4?
    • a. Neuromyelitis optica
    • b. Multiple sclerosis
    • c. Acute disseminated encephalomyelitis
    • d. Autoimmune encephalitis

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 3202
    • NMO is an autoimmune disease associated with a highly specific autoantibody directed against aquaporin-4 (AQP4) that is present in the sera of ~70% of patients with a clinical diagnosis of NMO. AQP4 is localized to the foot processes of astrocytes in close apposition to endothelial surfaces, as well as at paranodal regions near nodes of Ranvier. It is likely that AQP4 antibodies are pathogenic because passive transfer of AQP4 antibodies into laboratory animals can reproduce histologic features of the disease; complement fixation is thought to mediate astrocyte injury.

    • 2. Porta hepatis lies between:
    • a. Quadrate and Caudate lobe
    • b. Caudate lobe and Segment II
    • c. Segment VI and Segment VII
    • d. Segment VIi and Segment VIII

    • Ans: a
    • Ref: Gray’s anatomy, 41st Edition; Page No: 1165
    • The porta hepatis is a deep transverse fissure on the inferior surface of the liver. It is situated between the quadrate lobe anteriorly and the caudate process posteriorly, and contains the portal vein, hepatic artery and hepatic nervous plexuses as they ascend into the parenchyma of the liver, and the right and left hepatic ducts and some lymph vessels that emerge from the liver.

    • 3. Gunn sign is?
    • a. Silver wiring of arterioles
    • b. Deflection of veins at arteriovenous crossing
    • c. Copper wiring of arterioles
    • d. Tapering of veins on the either side of the crossings

    • Ans: d
    • Ref: AK Khurana Ophthalmology 6th Edition, Page No: 272- 73
    • Gunn sign is seen in grade III hypertensive retinopathy.
    • The other findings in grade III hypertensive retinopathy include
    •  copper wiring of arterioles
    •  banking of veins distal to arteriovenous crossings
    •  right-angle deflection of veins
    •  flame shaped hemorrhages
    •  cotton wool spots
    •  hard exudates

    • 4. Screening test for lead is measurement of:
    • a. Coproporphyrin in urine
    • b. Amino-levulinic acid in urine
    • c. Lead in blood
    • d. Lead in urine

    • Ans: a
    • Ref: Park PSM 23rd Edition, Page No: 808
    • Diagnosis of lead poisoning is based on
    • Laboratory tests:
    • • Coproporphyrin in urine (CPU): Measurement of CPU is a useful screening test. In non-exposed persons, it is less than 150 microgram/litre.
    • • Amino levulinic acid in urine (ALAU): If it exceeds 5 mg/litre, it indicates clearly lead absorption.
    • • Lead in blood and urine: Measurement of lead in blood or urine requires refined laboratory techniques. They provide quantitative indicators of exposure. Lead in urine of over 0.8 mg/litre (normal is 0.2 to 0.8 mg) indicates lead exposure and lead absorption. A blood level of 70μg/100 ml is associated with clinical symptoms.
    • • Basophilic stippling of RBC: Is a sensitive parameter of the hematological response.
    • A useful screening test is Coproporphyrin in Urine (CPU)
    • Lead Poisoning is known as 'Plumbism, Saturnism or Painter's Colic
    • Clinical picture of lead poisoning:
    • • Facial pallor: Earliest and most consistent sign
    • • Anemia: Microcytic hypochromic
    • • Punctate basophilia or basophilic stippling of RBCs
    • • Burtonian Line: Lead sulphide line on gums (upper jaw)
    • • Lead colic: Constipation (but sometimes diarrhea)
    • • Lead Palsy (Peripheral neuropathy Wrist drop or Foot drop
    • • Lead encephalopathy
    • • CNS effects: mostly due to organic lead compounds
  47. 47
    Answers & Winners of QUIZ for CEE MD/MS Based Model Test [Saturday, 11 AM, Bhadra 20]

    • 1. While performing CPR on an infant, another rescuer appears on the scene, what do you do next?
    • a. Immediately transport the patient
    • b. Wait until exhausted, then switch
    • c. Have the second rescuer help with CPR, to minimize fatigue
    • d. Have the second rescuer begin ventilations; ratio 30:2

    • Ans: c
    • The ratio of two-person CPR for infants and children is 15:2. One-person CPR for all ages is 30:2.
    • To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR)

    • 2. Object permanence milestone develop at:
    • a. 6 months
    • b. 9 months
    • c. 12 months
    • d. 15 months

    • Ans: b
    • Ref: Nelson pediatrics, 20th Edition, Page No: 70,75
    • A major milestone is the achievement by 9 months is of of object permanence (constancy), the understanding that objects continue to exist, even when not seen.
    • It is firmly established at 18-24 months.

    • 3. A 5-year-old girl is brought to urgent care for difficulty breathing. For the past few days, she has had low-grade fevers, a runny nose, and a slight cough. On physical exam, she has a seal-like barking cough and audible inspiratory stridor. There is accessory muscle use with breathing. Her lung exam was normal without any wheezes. Diagnosis is:
    • a. Acute epiglottis
    • b. Laryngotracheobronchitis (Croup)
    • c. Tracheobronchitis
    • d. None of above

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Chapter: 382
    • Croup:
    • - Most common cause of acute upper airway obstruction
    • - Mild upper RTI for 1-3 days followed by upper airway obstruction
    • - Barking cough, hoarseness, inspiratory stridor,
    • - X-ray shows subglottic narrowing or Steeple sign

    • 4. Uveitis at birth may be due to
    • a. Staph aureus carriage in the birth canal of the mother
    • b. Congenital syphilis
    • c. Adeno virus
    • d. Streptococcus Group B

    • Ans: b
    • Ref: AK Khurana Ophthalmology 4th Edition, Page No: 438
    • Ocular lesions of congenital syphilis are: interstitial keratitis, iridocyclitis (anterior uveitis) and chorioretinitis (posterior uveitis).

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Sanjit Jaiswal
    • - Dr Manisha Shah

    • Lucky draw winners:
    • - Dr Aneel Kharel
    • - Dr Sandeep Khadka

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to CEE MD/MS Based Model Test [Saturday, 11 AM, Bhadra 20]
  48. 48
    • 1. Axillary vein is continuation of:
    • a. Radial vein
    • b. Subclavian vein
    • c. Basilic vein
    • d. Brachial vein

    • Ans: c
    • Ref: Gray’s anatomy, 41st Edition; Page No: 830
    • Axillary vein begins at the lower border of teres major and ascends to the outer border of the first rib, where it becomes the subclavian vein. It is joined by the brachial vein near subscapularis, and by the cephalic vein near its costal end; other tributaries follow the axillary arterial branches.

    • 2. What is the amount of potassium chloride in WHO-ORS?
    • a. 1.5 gm/L
    • b. 2.6 gm/L
    • c. 2.9 gm/L
    • d. 4.6 gm/L

    • Ans: a
    • Ref: OP Ghai Pediatrics 9th Edition, Page No: 289
    • Composition of WHO recommended ORS:
    • Constituent in gm/L
    • • Sodium chloride 2.6
    • • Glucose, anhydrous 13.5
    • • Potassium chloride 1.5
    • • Trisodium citrate, dehydrate 2.9
    • Osmole in mmol/L
    • • Sodium 75
    • • Chloride 65
    • • Glucose, anhydrous 75
    • • Potassium 20
    • • Citrate 10
    • • Total osmolarity: 245

    • 3. True about cluster sampling all except:
    • a. Sample size same as simple random
    • b. It is two stage sampling
    • c. Cheaper than other methods
    • d. It is a method for rapid assessment

    • Ans: a
    • Ref: Mahajan Biostatistics 8th Edition, page No: 125
    • Cluster Sampling
    • A cluster is a randomly selected group. This method is used when units of population are natural groups or clusters such as villages, wards, blocks, slums of a town, factories, work-shops or children of a school, etc.
    • From the chosen clusters, 30 in number, the entire population is surveyed. Cluster sampling gives a higher standard error but the data collection in this method is simpler and involves less time and cost than in other sampling techniques.

    • 4. With oral iron therapy, rise in Hb% can be seen after:
    • a. 1 week
    • b. 3 weeks
    • c. 4 weeks
    • d. 6 weeks

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 310
    • Rate of improvement: The improvement should be evident within 3 weeks of the therapy. After a lapse of few days, the hemoglobin concentration is expected to rise at the rate of about 0.7 gm/ 100 ml/week.
  49. 49
    • 1. Surface cleaning agent that acts by lowering surface tension is:
    • a. Cleaner
    • b. Detergent
    • c. Germicide
    • d. Sanitizer

    • Ans: b
    •  Asepsis: Prevention of contact with microorganisms
    •  Cleaning: Removal of adherent visible blood/soil/proteinaceous substances/ microorganisms/debris from surfaces, crevices, serrations, joints, lumens of instruments/devices/equipment by manual/mechanical process for handling or further decontamination
    •  Detergent: Surface cleaning agent (hydrophilic and lipophilic component) that acts by lowering surface tension
    •  Disinfection: Thermal or chemical destruction of most of the pathogens
    •  Germicide: Agent that destroys microorganisms, especially pathogens
    •  Hospital disinfectant: Disinfectant registered for use in any medical facility; efficacy is demonstrated against Salmonella choleraesuis, Staphylococcus aureus, Pseudomonas aeruginosa
    •  Sanitizer: Agent that reduces number of bacterial contaminants to safe levels as per public health requirements (mainly used for inanimate objects)
    •  Sterile: State of being free from all living microorganisms

    • 2. In ECG, total electrical alternans (P-QRS-T) with sinus tachycardia is a relatively specific sign of?
    • a. Myocardial ischemia
    • b. Myocarditis
    • c. Pericardial effusion
    • d. Pneumothorax

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1458
    • Total electrical alternans (P-QRS-T) with sinus tachycardia (beat-to-beat alternation in one or more components of ECG) is a relatively specific sign of pericardial effusion with cardiac tamponade due to periodic swinging motion of heart in effusion at a frequency exactly half of heart rate.

    • 3. Irreversible steps in Glycolysis are all except:
    • a. Enolase
    • b. Phosphofructokinase
    • c. Pyruvate Kinase
    • d. Hexokinase

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 170-172
    • Irreversible Steps of Glycolysis
    • • Hexokinase
    • • Phosphofructokinase
    • • Pyruvate Kinase.
    • All the Kinases are irreversible except 1,3 Bisphospho Glycerate Kinase which is reversible.

    • 4. Which of the following drug is associated with highest cardiac mortality?
    • a. Rofecoxib
    • b. Nicorandil
    • c. Losartan
    • d. Metoprolol

    • Ans: a
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 7th Edition, Page No: 199
    • Rofecoxib was withdrawn due to increased incidence of cardiovascular events. The Adenoma Prevention with Celecoxib (APC) trial has also been terminated due to 2.5 fold increase in risk of major fatal/nonfatal cardiovascular events.
  50. 50
    Basics-USMLE Step 1 First Aid Based QUIZ: Answers and Winners

    • 1. Which of the following is not a postsplenectomy blood finding?
    • a. Howell-Jolly bodies
    • b. Target cells
    • c. Thrombocytosis
    • d. Lymphopenia

    • Ans: d
    • Ref: USMLE Step 1 First Aid 2020, Page No: 98
    • Postsplenectomy blood findings:
    • • Howell-Jolly bodies (nuclear remnants)
    • • Target cells
    • • Thrombocytosis (loss of sequestration and removal)
    • • Lymphocytosis (loss of sequestration)

    • 2. Not consistent with apoptosis:
    • a. ATP-independent
    • b. Both intrinsic and extrinsic pathways activate caspases
    • c. Cell membrane typically remains intact
    • d. DNA laddering is a sensitive indicator

    • Ans: a
    • Ref: USMLE Step 1 First Aid 2020, Page No: 208
    • Apoptosis
    • • ATP-dependent programmed cell death.
    • • Intrinsic and extrinsic pathways; both pathways activate caspases (cytosolic proteases), leads to cellular breakdown including cell shrinkage, chromatin condensation, membrane blebbing, and formation of apoptotic bodies, which are then phagocytosed.
    • • Characterized by deeply eosinophilic cytoplasm and basophilic nucleus, pyknosis, and karyorrhexis.
    • • Cell membrane typically remains intact without significant inflammation (unlike necrosis).
    • • DNA laddering (fragments in multiples of 180 bp) is a sensitive indicator of apoptosis.

    • 3. Coronary vasospasm may be caused:
    • a. Oxygen
    • b. Amphetamines
    • c. Beta blockers
    • d. Nitroglycerine

    • Ans: b
    • Ref: USMLE Step 1 First Aid 2020, Page No: 248
    • Coronary vasospasm may be caused by Cocaine, Amphetamines, Sumatriptan, Ergot alkaloids (CASE)

    • 4. Fetal erythropoiesis occurs earliest in:
    • a. Yolk sac
    • b. Spleen
    • c. Bone marrow
    • d. Lymph node

    • Ans: a
    • Ref: USMLE Step 1 First Aid 2020, Page No: 404
    • Fetal erythropoiesis occurs in:
    • • Yolk sac (3–8 weeks)
    • • Liver (6 weeks–birth)
    • • Spleen (10–28 weeks)
    • • Bone marrow (18 weeks to adult)

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Subash Lamichhane
    • - Dr Niraj Acharya

    • Lucky draw winners:
    • - Dr Rajya Prakash Rai
    • - Dr Sushil Bhatta

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening Basics-USMLE Step 1 First Aid Based Online Model Test [07:00 PM, Bhadra 22, 2077, Monday].
  51. 51
    Answers and Winners of QUIZ for Today evening CEE MD/MS Based Online Model Test [07:00 PM, Bhadra 24, 2077, Wednesday].

    • 1. Clara cells are found in:
    • a. Trachea
    • b. Proximal bronchioles
    • c. Terminal bronchioles
    • d. Alveoli

    • Ans: c
    • Ref: IB Singh’s Human Histology; 4thedition; Page No: 214
    • Cells of Clara are non-ciliated cells present predominantly in terminal bronchioles produce secretion (surfactant lipoproteins)Which spreads over alveolar cells forming a film that reduces surface tension and thus share functional similarities with type II alveolar cells.

    • 2. Which is not feature of pseudocyesis?
    • a. Amenorrhea
    • b. Fetal heart sound audible
    • c. Enlargement of abdomen
    • d. Fetal movement

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 81-82
    • Pseudocyesis (Syn: Phantom, spurious, false pregnancy):
    • • It is a psychological disorder where the woman has the false but firm belief that she is pregnant although no pregnancy exists. The woman often is infertile who has an intense desire to have a baby. The conspicuous feature is cessation of menstruation.
    • • Other confusing manifestations are gradual enlargement of the abdomen because of deposition of fat, secretion from the breasts and intestinal movement, imagining it to be fetal movement. In some cases, the condition continues until eventually spurious labor sets in.
    • • Obstetric examination reveals absence of positive signs of pregnancy. Examination with ultrasound and/or immunological tests for pregnancy may be required to negate the diagnosis.

    • 3. Banking of veins distal to A-V crossing seen in hypertensive retinopathy is:
    • a. Bonnet sign
    • b. Gunn sign
    • c. Salu sign
    • d. None of the above

    • Ans: a
    • Ref: AK Khurana Ophthalmology 6th Edition, Page No: 275
    • Arteriovenous nicking is the hallmark of hypertensive retinopathy and occurs where arterioles crosses and compresses the vein, as the vessels share a common adventitious sheath. Also known as A-V crossing changes, these include:
    • • Salu’s sign: deflection of veins at the A-V crossings
    • • Bonnet sign: banking of veins distal to A-V crossings
    • • Gunn sign: tapering of veins on either side of the A-V crossings.

    • 4. Which of the following declaration is adopted by WMA deals with therapeutic abortion?
    • a. Declaration of Geneva
    • b. Declaration of Helsinki
    • c. Declaration of Tokyo
    • d. Declaration of Oslo

    • Ans: d
    • Ref: Gautam Biswas Forensic Medicine, 3rd Edition, Page No: 6
    • • Hippocratic Oath: The Hippocratic Oath is traditionally taken by physicians, in which certain ethical guidelines are laid out. Several parts of the Oath have been removed or re-worded over the years in various countries, schools and societies.

    • Declaration of Geneva: The declaration of Geneva was intended as a revision of the Hippocrates Oath to a formulation of that oaths’ moral truth that could be comprehended and acknowledged modernly. It was adopted by the General Assembly of the World Medical Association (WMA) at Geneva in 1948 and amended in 1968, 1984, 1994, 2005 and 2006.

    • Declaration of Tokyo: This was adopted in 1975 (amended in 2005 and 2006) during the assembly of the WMA. It refers to the guidelines for doctors concerning torture, degradation or cruel treatment of prisoners.

    • Declaration of Helsinki: The WMA originally developed this declaration in 1964 and underwent major revision in 1975. It refers to the ethical principles for medical research involving human subjects, including research on identifiable human material and data.

    • Declaration of Oslo: It was a statement by the WMA in 1970 on therapeutic abortion and amended in 1983 and 2006.

    • Declaration of Malta: This was adopted by the WMA in 1991 (revised in 1992 and 2006) for hunger strikers. The principle of beneficence urges physicians to resuscitate them, but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made.

    • Declaration of Lisbon: This was adopted by the WMA in 1981 (amended in 1995 and 2005). The declaration represents some of the principal rights of the patient that the medical profession endorses and promotes.

    • Declaration of Ottawa: This declaration on child health was adopted by the WMA in 1998 (amended in 2009). Physicians along with parents and with world leaders to advocate for healthy children.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Prabin Paudel
    • - Dr Uttam Mahat

    • Lucky draw winners:
    • - Dr Babin Acharya
    • - Dr Manisha Shah

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening CEE MD/MS Based Online Model Test [07:00 PM, Bhadra 24, 2077, Wednesday].
  52. 52
    Answers and Winners of QUIZ for CEE MD/MS Based Online Model Test [11:00 AM, Bhadra 27, 2077, Saturday].

    • 1. A patient with COPD, under long acting beta-2 agonist and muscarinic antagonist, was found to have frequent exacerbations. On investigation, his blood eosinophil count was found to be 70 cells per microliter. Which of the following drug is preferred for such condition?
    • a. Inhalation corticosteroid
    • b. Oral corticosteroid
    • c. Azithromycin
    • d. Statins

    • Ans: c
    • Ref: Gold guideline, 2020, Page No: 87
    • In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways. Blood eosinophil counts < 100 cells/µL can be used to predict a low likelihood of a beneficial ICS response: Escalation to LABA/LAMA/ICS. A beneficial response after the addition of ICS may be observed at blood eosinophil counts ≥ 100 cells /µL, with a greater magnitude of response more likely with higher eosinophil counts. Add roflumilast or azithromycin if blood eosinophils < 100 cells/µL.

    • 2. Maternal antibodies are present in the newborn against all of the following disease except:
    • a. Diphtheria
    • b. Tetanus
    • c. Pertussis
    • d. Measles

    • Ans: c
    • Ref: Park PSM 23rd Edition, Page No: 163
    • Infants are susceptible to infection from birth because maternal antibody does not appear to give them protection. There is no cross immunity with B. parapertussis.

    • 3. Which nerve is commonly harvested to be used as graft?
    • a. Dorsal cutaneous nerve
    • b. Peroneal nerve
    • c. Sural nerve
    • d. Tibial nerve

    • Ans: c
    • Ref: Apley and Soloman’s Orthopaedics, 10th edition, page 285 – 286
    • • Free autogenous nerve grafts can be used to bridge gaps too large for direct suture. The sural nerve is most commonly used; up to 40 cm can be obtained from each leg.
    • • Because the nerve diameter is small, several strips may be used (cable graft). The graft should be long enough to lie without any tension, and it should be routed through a well-vascularized bed.
    • • The graft is attached at each end either by fine sutures or with fibrin glue. It is crucial that the motor and sensory fascicles are appropriately connected by the graft.

    • 4. First change seen with salicylate poisoning is:
    • a. Metabolic acidosis
    • b. Respiratory acidosis
    • c. Metabolic alkalosis
    • d. Respiratory alkalosis

    • Ans: d
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Table: 473e-4
    • Salicylate poisoning:
    • Increased sensitivity of CNS respiratory center to changes in and stimulates respiration. Uncoupling of oxidative phosphorylation, inhibition of Krebs cycle enzymes, and stimulation of carbohydrate and lipid metabolism generate unmeasured endogenous anions and cause anionic gap metabolic acidosis (AGMA).
    • Clinical features:
    • • Initial nausea, vomiting, hyperventilation, alkalemia, alkaluria
    • • Subsequent alkalemia with both respiratory alkalosis and anionic gap metabolic acidosis (AGMA) and paradoxical aciduria
    • • Late acidemia with CNS and respiratory depression
    • • Cerebral and pulmonary edema in severe cases
    • • Hypoglycemia, hypocalcemia, hypokalemia, and seizures can occur.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Navneet Rauniyar
    • - Dr Binita Karki

    • Lucky draw winners:
    • - Dr Tripti Devkota
    • - Dr Bijay Ranabhat

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to CEE MD/MS Based Online Model Test [11:00 AM, Bhadra 27, 2077, Saturday].
  53. 53
    • 1. Most common pathology associated with ascending aortic aneurysm is
    • a. Medial degeneration
    • b. Atherosclerosis
    • c. Trauma
    • d. Embolism

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1918
    • • The clinical manifestations and natural history of thoracic aortic aneurysms depend on their location.
    • • Medial degeneration is the most common pathology associated with ascending aortic aneurysms, whereas atherosclerosis is the condition most frequently associated with aneurysms of the descending thoracic aorta. The average growth rate of thoracic aneurysms is 0.1–0.2 cm per year.
    • • Thoracic aortic aneurysms associated with Marfan’s syndrome or aortic dissection may expand at a greater rate.
    • • The risk of rupture is related to the size of the aneurysm and the presence of symptoms, ranging approximately from 2–3% per year for thoracic aortic aneurysms <4.0 cm in diameter to 7% per year for those >6 cm in diameter.

    • 2. Satellitism is seen in cultures of:
    • a. Hemophilus
    • b. Streptococcus
    • c. Klebsiella
    • d. Proteus

    • Ans: a
    • Ref: Jawetz’s Medical Microbiology; Lange; 26th Edition, Page No: 265
    • H influenzae does not grow on sheep blood agar except around colonies of staphylococci (“satellite phenomenon”).
    • On chocolate agar, flat, grayish brown colonies with diameters of 1–2 mm are present aft er 24 hours of incubation.

    • 3. Opposite testis lies horizontally because of the presence of mesorchium. The sign is:
    • a. Prehn’s
    • b. Deming’s sign
    • c. Angell’s sign
    • d. None

    • Ans: c
    • Ref: SRB's Manual of Surgery; 5th Edition, Page No: 1082
    • • Acute epididymo-orchitis—elevation of the scrotum for one hour, relieves the pain of acute epididymo-orchitis but aggravates in case of torsion testis (Prehn’s sign).
    • • Deming’s sign: Affected testis is positioned high because of twisting of cord and spasm of cremaster muscle.
    • • Angell’s sign: Opposite testis lies horizontally because of the presence of mesorchium.

    • 4. Left-to-right shunt is not seen in?
    • a. Atrial septal defect
    • b. Patent ductal arteriosus
    • c. Tetralogy of Fallot
    • d. Ventricular septal defect

    • Ans: c
    • Ref: Robbins Basic Pathology, 10th edition, page 404 – 407
    • • Disorders associated with Left-to-right shunts are the most common types of congenital cardiac malformations. They include atrial septal defects (ASDs), ventricular septal defects (VSDs), and patent ductus arteriosus (PDA).
    • • Cardiac malformations associated with right-to-left shunts are distinguished by early cyanosis. This occurs because poorly oxygenated blood from the right side of the heart flows directly into the arterial circulation. Two of the most important conditions associated with cyanotic congenital heart disease (right to left shunts) are tetralogy of Fallot and transposition of the great vessels.

    • The four cardinal features of tetralogy of Fallot are:
    • o VSD
    • o Right ventricular outflow tract obstruction (subpulmonic stenosis)
    • o Overriding of the VSD by the aorta
    • o Right ventricular hypertrophy
  54. 54
    Answers and Winners of QUIZ for IOM PAST QUESTION BASED Model test of Bhadra 29 (Monday , 07:00 PM).

    • 1. An old aged male presents with oculomotor nerve palsy in right side & hemiplegia on left side. What is the probable diagnosis? [IOM 2019]
    • a. Wallenberg syndrome
    • b. Parinaud syndrome
    • c. Weber syndrome
    • d. Benedikt’s syndrome

    • Ans: c
    • Ref: Weber syndrome by Vladimir Kaye in Medscape
    • Weber syndrome occurs with an occlusion of the median and/or paramedian perforating branches of the basilar artery. Typical clinical findings include ipsilateral CN III palsy, ptosis, and mydriasis (ie, damage to parasympathetic fibers of CN III) with contralateral hemiplegia. Weakness of the lower face (corticospinal and corticobulbar tracts) may be noted.

    • 2. In sickle cell anemia [IOM 2007]
    • a. Glutamic acid replaced with valine
    • b. Valine is replaced by glycine
    • c. Lysine is replaced by leucine
    • d. Leucine is replaced by lysine

    • Ans: a
    • Ref: Robbins Basic Pathology 10th Edition, Page No: 445
    • • Sickle cell anemia is caused by a single amino acid substitution in β-globin that results in a tendency for deoxygenated HbS to self-associate into polymers.
    • • Normal hemoglobins are tetramers composed of two pairs of similar chains. On average, the normal adult red cell contains 96% HbA (α2β2), 3% HbA2 (α2δ2), and 1% fetal Hb (HbF, α2γ2).
    • • In patients with sickle cell anemia, HbA is completely replaced by HbS, whereas in heterozygous carriers, only about half is replaced.
    • • HbS differs from HbA by having a valine residue instead of a glutamate residue at the 6th amino acid position in β-globin.

    • 3. Spontaneous mutation occurs from [IOM 2010]
    • a. Replication errors
    • b. Restoring original genetic makeup
    • c. Chemical mutagenesis
    • d. Radiation mutagenesis

    • Ans: a
    • Ref: An Introduction to Genetic Analysis. 7th edition; Griffiths AJFet al; New York: W. H. Freeman; 2000.
    • Spontaneous mutations can be generated by different processes. Replication errors and spontaneous lesions generate most of the base-substitution and frameshift mutations. Replication errors may also cause some deletions that occur in the absence of mutagenic treatment.

    • 4. Utero-placental circulation starts at [IOM 2011]
    • a. 2nd week
    • b. 3rd week
    • c. 4th week
    • d. 5th week

    • Ans: a
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 30
    • Important Events Following Fertilization
    • • ‘0’ hour — Fertilization (day-15 from LMP)
    • • 30 hours — 2 cell stage (blastomeres)
    • • 40–50 hours — 4 cell stage
    • • 72 hours — 12 cell stage
    • • 96 hours — 16 cell stage. Morula enters the uterine cavity
    • • 5th day — Blastocyst
    • • 4–5th day — Zona pellucida disappears
    • • 5–6th day — Blastocyst attachment to endometrial surface
    • • 6–7th day — Differentiation of cyto and syncytiotrophoblastic layers
    • • 10th day — Synthesis of hCG by syncytiotrophoblast
    • • 9–10th day — Lacunar network forms
    • • 10–11th day — Trophoblasts invade endometrial sinusoids establishing uteroplacental circulation; Interstitial implantation completed with entire decidual coverage
    • • 13th day — Primary villi
    • • 16th day — Secondary villi
    • • 21st day — Tertiary villi
    • • 21st–22nd day — Fetal heart. Fetoplacental circulation

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Paras Mani Bhatta
    • - Dr Sushil Parajuli

    • Lucky draw winners:
    • - Dr Amit Singh
    • - Dr Srijana Rawal

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Tomorrow evening IOM PAST QUESTION BASED Model test of Bhadra 29 (Monday , 07:00 PM).
  55. 55
    Answers and Winners of QUIZ for Today evening CEE MD/MS Based Model test of Bhadra 31 (Wednesday, 07:00 PM).

    • 1. When is transcervical chorionic villus sampling carried out?
    • a. 6 – 8 weeks
    • b. 10 – 13 weeks
    • c. 18 – 20 weeks
    • d. 10 weeks – term

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 129
    • • Chorionic Villus Sampling (CVS) is performed for prenatal diagnosis of genetic disorders. It is carried out transcervically between 10 weeks and 13 weeks and transabdominally from 10 weeks to term.
    • • Diagnosis can be obtained by 24 hours, and as such, if termination is considered, it can be done in the first trimester safely.

    • 2. Insulin causes uptake of glucose in
    • a. Liver
    • b. Skeletal muscle
    • c. Kidney
    • d. Brain

    • Ans: b
    • Ref: Guyton’s Physiology 11th Edition, Page No: 963
    • • Within seconds after insulin binds with its membrane receptors, the membranes of about 80 per cent of the body’s cells markedly increase their uptake of glucose. This is especially true of muscle cells and adipose cells but is not true of most neurons in the brain.
    • • The increased glucose transported into the cells is immediately phosphorylated and becomes a substrate for all the usual carbohydrate metabolic functions.
    • • The increased glucose transport is believed to result from translocation of multiple intracellular vesicles to the cell membranes; these vesicles carry in their own membranes multiple molecules of glucose transport proteins, which bind with the cell membrane and facilitate glucose uptake into the cells.

    • 3. False about structures passing through transpyloric plane is?
    • a. It is about midway between jugular notch and pubic symphysis.
    • b. It transects the lower aspect of L1 vertebrae.
    • c. It crosses through the hilum of right kidney.
    • d. It crosses through the lower pole of left kidney.

    • Ans: d
    • Ref: Gray’s anatomy for students, 4th Edition, Page 267
    • • The transpyloric plane is a horizontal plane that transects the body through the lower aspect of vertebra L1.
    • • It is about midway between the jugular notch and the pubic symphysis, and crosses the costal margin on each side at roughly the ninth costal cartilage.
    • • It crosses through the opening of the stomach into the duodenum (the pyloric orifice), which is just right to the body of L1; the duodenum then makes a characteristic C-shaped loop on the posterior abdominal wall and crosses the midline to open into the jejunum just to the left of the body of vertebra LII.
    • • It crosses through the body of the pancreas.
    • • It approximates the position of the hila of the kidneys.; though because the left kidney is slightly higher than the right, the transpyloric plane crosses through the inferior aspect of the left hilum and superior part of the right hilum.

    • 4. 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.

    • Winners:
    • Fastets correct answer respondents:
    • - Dr Prabhat Risal
    • - Dr Kesha Tandukar

    • Lucky draw winners:
    • - Dr Kalpana Acharya
    • - Dr Sheetal Shrestha

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening CEE MD/MS Based Model test of Bhadra 31 (Wednesday, 07:00 PM).
  56. 56
    Answers and Winners of QUIZ for Today's CEE MD/MS Based Model test of Asoj 3 (Saturday, 11:00 AM).

    • 1. In COVID-19, Hemophagocytic lymphohistiocytosis is due to:
    • a. Low blood pressure
    • b. Drug side effect
    • c. Cytokine storm
    • d. High oxygen supplementation

    • Ans: c
    • • Hemophagocytic lymphohistiocytosis (HLH) is a non-malignant but often-fatal disorder of immune dysregulation affecting multiple organs. It is also known as macrophage activation syndrome when occurring in the setting of a rheumatologic disorder.
    • • Some of the clinical characteristics observed in the more severe cases of COVID-19 are reminiscent of hemophagocytic lymphohistiocytosis (HLH), a severe, life-threatening inflammatory syndrome associated with intense cytokine release (also known as a “cytokine storm”).

    • 2. A 28 year old female is planned for laparoscopic cholecystectomy for frequently symptomatic cholelithiasis. Surgeon needs to stay aware about Calot triangle, which is an important landmark for:
    • a. Right hepatic artery
    • b. Left hepatic artery
    • c. Cystic artery
    • d. Gastroduodenal artery

    • Ans: c
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 1189
    • • The cystic artery, a branch of the right hepatic artery, usually arises behind the common hepatic duct.
    • • Occasionally, an accessory cystic artery arises from the gastroduodenal artery.
    • • In 15% of cases the right hepatic artery and or the cystic artery crosses in front of the common hepatic duct and the cystic duct.
    • Calot’s triangle, or the hepatobiliary triangle, was initially described by Calot as the space bordered by the cystic duct inferiorly, the common hepatic duct medially and the superior border of the cystic artery.
    • This has been modified in contemporary literature to be the area bound superiorly by the inferior surface of the liver, laterally by the cystic duct and the medial border of the gallbladder and medially by the common hepatic duct. It is an important surgical landmark as the cystic artery usually can be found within its boundaries and should be identified by surgeons performing a cholecystectomy to avoid damage to the extrahepatic biliary system.

    • 3. False about β-oxidation of fatty acids are:
    • a. It is the oxidation of fatty acids on the β-carbon atom.
    • b. It results in sequential removal of a two carbon fragment.
    • c. It occurs completely inside mitochondria only
    • d. It occurs in cytosol and mitochondria in different stages.

    • Ans: c
    • Reference: Satyanarayana Biochemistry 4th Edition, Page 287
    • The fatty acids in the body are mostly oxidized by β-oxidation. It is defined as the oxidation of fatty acids on the β-carbon atom. This results in the sequential removal of a two carbon fragments, acetyl coA. Fatty acids are oxidized by most tissues of the body except brain, erythrocytes and adrenal medulla.
    • The β-oxidation of fatty acids involves 3 stages and occurs in:
    • • Activation of fatty acids occurs in cytosol
    • • Transport of fatty acids into mitochondria
    • • β-oxidation proper occurs in mitochondrial matrix

    • 4. What is Mittelschmerz syndrome?
    • a. Primary dysmenorrhea
    • b. Secondary dysmenorrhea
    • c. Ovular pain
    • d. Pelvic congestion pain

    • Ans: c
    • Ref: DC Dutta Textbook of Gynecology including Contraception; 6th Edition, Page No: 181
    • • Mittelschmerz syndrome (Ovular Pain): Ovular pain is not an infrequent complaint. It appears in the midmenstrual period. The pain is usually situated in the hypogastrium or in either iliac fossa.
    • • The pain is usually located on one side and does not change from side to side according to which ovary is ovulating. Nausea or vomiting is conspicuously absent. It rarely lasts more than 12 hours. It may be associated with slight vaginal bleeding or excessive mucoid vaginal discharge.
    • • The exact cause is not known. The probable factors are: (i) Increased tension of the Graafian follicle just prior to rupture, (ii) Peritoneal irritation by the follicular fluid following ovulation and (iii) Contraction of the tubes and uterus.
    • • Treatment is effective with assurance and analgesics. In obstinate cases, the cure is absolute by making the cycle anovular with contraceptive pills.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Sushil Sharma
    • - Dr Aashma Sharma

    • Lucky draw winners:
    • - Dr Sabina Thapaliya
    • - Dr Aseem Madhuri Anand

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today's CEE MD/MS Based Model test of Asoj 3 (Saturday, 11:00 AM).
  57. 57
    Answers and Winners of QUIZ for CEE MD/MS Based Model test of Asoj 7 (Wednesday, 07:00 PM).

    • 1. Which of the following Article of Constitution of Nepal guarantees Right against torture?
    • a. Article 17
    • b. Article 22
    • c. Article 31
    • d. Article 35

    • Ans: b
    • Constitution of Nepal 2015 (Nepali Name:नेपालको संविधान २०७२) is the present governing Constitution of Nepal. Nepal is governed according to the Constitution which came into effect on Sept 20, 2015, replacing the Interim Constitution of 2007.
    • The constitution of Nepal is divided into 35 parts, 308 Articles and 9 Schedules.
    • Fundamental rights guaranteed in the Constitution (Part 3)
    • • Right to Life of Dignity (Article 16)
    • • Right to Freedom (Article 17)
    • • Right to Equality (Article 18)
    • • Right regarding Justice (Article 20)
    • • Right against Torture (Article 22)
    • • Right to Information (Article 27)
    • • Right to Privacy (Article 28)
    • • Right to Fresh Environment (Article 30)
    • • Right regarding Education (Article 31)
    • • Right to Labour (Article 34)
    • • Right regarding Health (Article 35)
    • • Right regarding Food (Article 36)
    • • Women's Rights (Article 38)
    • • Children's Rights (Article 39)
    • • Right to Social Justice (Article 42)
    • • Right to Social Security (Article 43)
    • • Consumer's Rights (Article 44)

    • 2. In HIV patient required CD4 Count for organ transplant is greater than:
    • a. 200
    • b. 300
    • c. 400
    • d. 500

    • Ans: a
    • Ref: Pre-transplant CD4 count influences immune reconstitution and risk of infectious complications in HIV+ kidney allograft recipients; J. F. Suarez, Am J Transplant.
    • In order to be eligible for kidney transplant, HIV+ candidates must have a sustained undetectable viral load and CD4 count >200 cells/mm3. The optimal pre-transplant CD4 count above this threshold, however, remains to be defined.

    • 3. Characteristic square root sign in the ventricular waveform during diastole is seen with:
    • a. Cardiac tamponade
    • b. Constrictive pericarditis
    • c. Acute pericarditis
    • d. Myocarditis

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1845-46
    • • In constrictive pericarditis, right atrial pressure is elevated with a prominent “y” descent, indicating rapid filling of the right ventricle during early diastole.
    • • A diastolic dip and plateau or “square root sign,” in the ventricular waveforms due to an abrupt halt in ventricular filling during diastole; right ventricular and pulmonary artery pressures are elevated; and discordant pressure changes in the right and left ventricles with inspiration (right ventricular systolic pressure increases while left ventricular systolic pressure decreases) are observed.

    • 4. Which drug is specific MAO-B inhibitor?
    • a. Moclobemide
    • b. Selegiline
    • c. Tranylcypromine
    • d. Nialamide

    • Ans: b
    • Ref: KD Tripathi; 7th edition; Pg 129
    • • MAO-inhibition-Nialamide, tranylcypromine
    • • MAO-A inhibition-Moclobemide
    • • MAO-B inhibition-Selegiline
    • • COMT inhibition-Tolcapone, entacapone

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Aakanshya Shretsha
    • - Dr Bijay Rajbanshi

    • Lucky draw winners:
    • - Dr Bibek Keshari
    • - Dr Tej Narayan Yadav

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening CEE MD/MS Based Model test of Asoj 7 (Wednesday, 07:00 PM).
  58. 58
    • 1. A patients feels he is being followed and they are planning to do him harm. This is called:
    • a. Persecutory Delusion
    • b. Psychosis
    • c. Mania
    • d. Phobia

    • Ans: a
    • Ref: Niraj Ahuja Psychiatry 7th Edition, Page No: 56
    • The commonly seen delusions in schizophrenia include:
    • • Delusions of persecution (being persecuted against, e.g. ‘people are against me’).
    • • Delusions of reference (being referred to by others; e.g. ‘people are talking about me’).
    • • Delusions of grandeur (exaggerated self-importance; e.g. ‘I am God almighty’).
    • • Delusions of control (being controlled by an external force, known or unknown; e.g. ‘My neighbor is controlling me”).
    • • Somatic (or hypochondriacal) delusions (e.g. ‘there are insects crawling in my scalp’).

    • 2. ± 3 SD from mean covers how much area under normal distribution curve:
    • a. 66%
    • b. 68%
    • c. 95%
    • d. 99%

    • Ans: d
    • Ref: Mahajan Biostatistics 8th Edition, page No: 100
    • • Mean ± 1 SD limits; include 68.27% or roughly 2/3rd of all the observation. Out of the remaining 1/3rd observations, half, i.e. 1/6th will lie below the lower limit (mean –1 SD) and the other half, i.e. 1/6th will lie above the upper limit (mean + 1 SD). In other words, some 32% will lie outside the range, mean ± 1 SD.
    • • Mean ± 2 SD limits; include 95.45% of observations while 4.55% of observations will be outside these limits. Similarly, mean ± 1.96 SD limits, include 95% of all observations.
    • • Mean ± 3 SD limits include 99.73%. Mean ± 2.58 SD limits, include 99%.

    • 3. Quadriplegia which is severe in upper limbs than lower limbs is seen in which one of the following?
    • a. Brown Sequard Syndrome
    • b. Anterior Cord Syndrome
    • c. Posterior Cord Syndrome
    • d. Central Cord Syndrome

    • Ans: d
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2652
    • Central Cord Syndrome: This syndrome results from selective damage to the gray matter nerve cells and crossing spinothalamic tracts surrounding the central canal. In the cervical cord, the central cord syndrome produces arm weakness out of proportion to leg weakness and a “dissociated” sensory loss, meaning loss of pain and temperature sensations over the shoulders, lower neck, and upper trunk (cape distribution), in contrast to preservation of light touch, joint position, and vibration sense in these regions. Spinal trauma, syringomyelia, and intrinsic cord tumors are the main causes.

    • 4. 4-9 ribs notching is characteristic of:
    • a. Coarctation of aorta
    • b. Tetralogy of Fallot
    • c. Ventricular septal defect
    • d. Patent ductus arteriosus

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1525
    • COARCTATION OF THE AORTA
    • • Narrowing or constriction of the lumen of the aorta may occur any- where along its length but is most common distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum.
    • • Coarctation occurs in ~7% of patients with CHD, is more common in males than females, and is particularly frequent in patients with gonadal dysgenesis (e.g., Turner’s syndrome).
    • • Clinical manifestations depend on the site and extent of obstruction and the presence of associated cardiac anomalies, most commonly a bicuspid aortic valve. Circle of Willis aneurysms may occur in up to 10%.
    • • Headache, epistaxis, chest pressure, and claudication with exercise may occur, and attention is usually directed to the cardiovascular system when a heart murmur or hypertension in the upper extremities and absence, marked diminution, or delayed pulsations in the femoral arteries are detected on physical examination.
    • • Enlarged and pulsatile collateral vessels may be palpated in the intercostal spaces anteriorly, in the axillae, or posteriorly in the inter-scapular area. The upper extremities and thorax may be more developed than the lower extremities.
    • • A midsystolic murmur over the left interscapular space may become continuous if the lumen is narrowed sufficiently to result in a high-velocity jet across the lesion throughout the cardiac cycle. Additional systolic and continuous murmurs over the lateral thoracic wall may reflect increased flow through dilated and tortuous collateral vessels.
    • • ECG usually reveals LV hypertrophy. Chest x-ray may show a dilated left subclavian artery high on the left mediastinal border and a dilated ascending aorta. Indentation of the aorta at the site of coarctation and pre- and poststenotic dilatation (the “3” sign) along the left paramediastinal shadow are essentially pathognomonic.
    • Notching of the third to ninth ribs, an important radiographic sign, is due to inferior rib erosion by dilated collateral vessels.

    • 5. In Sick euthyroidism, the TFT pattern is:
    • a. ↑T3, ↑T4, ↑TSH
    • b. ↓T3, ↑ T4, ↑ TSH
    • c. ↑T3, ↑ T4, ↓TSH
    • d. ↓ T3, ↓ T4, ↓ TSH

    • Ans: d
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2299
    • • The most common hormone pattern in sick euthyroid syndrome (SES) is a decrease in total and unbound T3 levels (low T3 syndrome) with normal levels of T4 and TSH. The magnitude of the fall in T3 correlates with the severity of the illness.
    • • Very sick patients may exhibit a dramatic fall in total T4 and T3 levels (low T4 syndrome).
    • • Fluctuation in TSH levels also creates challenges in the interpretation of thyroid function in sick patients. TSH levels may range from <0.1 mIU/L in very ill patients, especially with dopamine or glucocorticoid therapy, to >20 mIU/L during the recovery phase of SES. The exact mechanisms underlying the subnormal TSH seen in 10% of sick patients and the increased TSH seen in 5% remain unclear but may be mediated by cytokines including IL-12 and IL-18.
  59. 59
    • 1. Which of the following is recommended for lay rescuers in CPR?
    • a. Complete CPR
    • b. COCPR
    • c. BOCPR
    • d. Any of the above

    • Ans: b
    • For lay rescuers, compression-only CPR (COCPR) is recommended.
    • Positioning for CPR is as follows:
    • • CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum
    • • Delivery of CPR on a mattress or other soft material is generally less effective
    • • The person giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest

    • 2. Which of the following is a feature of temporal arteritis?
    • a. Giant cell arteritis
    • b. Granulomatous vasculitis
    • c. Necrotizing vasculitis
    • d. Leukocytoclastic vasculitis

    • Ans: a
    • Ref: Robbins Basic Pathology 10th Edition, Page No: 384
    • Giant Cell (Temporal) Arteritis
    •  Giant cell (temporal) arteritis is a chronic inflammatory disorder, typically with granulomatous inflammation, that principally affects large- to small-sized arteries in the head.
    •  The temporal arteries are not more vulnerable than other arteries, but have leant their name to the disorder because the diagnosis is typically established by biopsy of these vessels.
    •  Vertebral and ophthalmic arteries, as well as the aorta (giant cell aortitis), are other common sites of involvement.
    •  Because ophthalmic artery vasculitis can lead to sudden and permanent blindness, affected individuals must be promptly diagnosed and treated promptly. It is the most common form of vasculitis among older adults in developed countries.

    • 3. The crystalline lens derives its nutrition from:
    • a. Blood vessels
    • b. Connective tissue
    • c. Aqueous and vitreous
    • d. Capsule of the lens

    • Ans: c
    • Ref: AK Khurana Ophthalmology 6th Edition, Page No: 181
    • Source of nutrient supply:
    • – The crystalline lens, being an avascular structure is dependent for its metabolism on chemical exchanges with the aqueous humour.
    • – Some nutrition is also derived from the vitreous humour, but it is much less than that derived from the aqueous humour.

    • 4. Barton’s fracture of the wrist:
    • a. Involves radio carpal subluxation
    • b. Is a severe form of a colles’ fracture
    • c. Is often treated by cast
    • d. All of the above

    • Ans: a
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 3
    • • ColIe’s fracture and smith’s fracture: Extra-articular fracture of distal end radius.
    • • Barton‘s fracture: Intra-articular fracture of distal end radius with carpus dislocation.
  60. 60
    Answers and Winners of QUIZ for to CEE MD/MS Based Model test of Asoj 10 (Saturday, 11:00 AM).

    • 1. Phage mediate transfer of cDNA into host is known as:
    • a. Transduction
    • b. Transformation
    • c. Transmission
    • d. Conjugation

    • Ans: a
    • Ref: Jawetz’s Medical Microbiology; Lange; 27th Edition, Page No: 107, 108
    • Conjugation requires donor cell-to-recipient cell contact to transfer only one strand of DNA. The recipient completes the structure of double-stranded DNA by synthesizing the strand that complements the strand acquired from the donor.
    • In transduction, donor DNA is carried in a phage coat and is transferred into the recipient by the mechanism used for phage infection.
    • Transformation, the direct uptake of “naked” donor DNA by the recipient cell, may be natural or forced. Forced transformation is induced in the laboratory, where, after treatment with high salt and temperature shock, many bacteria are rendered competent for the uptake of extracellular plasmids. The capacity to force bacteria to incorporate extracellular plasmids by transformation is fundamental to genetic engineering.

    • 2. How will you break bad news?
    • a. Ignore the patient's perception
    • b. Address the patient's emotions with empathetic responses
    • c. Inform the patient and walk over
    • d. Invite the patient after discharge and inform

    • Ans: b
    • Breaking bad news
    •  set up the interview
    •  assess the patient's perception
    •  obtain the patient's invitation (i.e. permission)
    •  give the patient the necessary knowledge
    •  address the patient's emotions with empathetic responses

    • 3. Which of the following skin has got the fastest rate of absorption of drugs/chemicals?
    • a. Scrotal skin
    • b. Postauricular skin
    • c. Armpit
    • d. Scalp

    • Ans: a
    • REF: Goodman and Gilman, 11th Edition Page No: 3
    • The rate of absorption of chemicals through the skin follows the following scheme from fastest to slowest:
    • • Scrotal>Forehead,Postauricular>Armpit>Scalp>Back=Abdomen>Palm=Under surface of foot
    • • Such differences exist due to a combination of skin thickness, hair follicles, density of capillaries in the skin, lipid content and degree of skin hydration.

    • 4. Nerve supply of circumvallate papillae is:
    • a. Hypoglossal nerve
    • b. Glossopharyngeal nerve
    • c. Lingual nerve
    • d. Chorda tympani

    • Ans: b
    • Ref: BDC Human Anatomy, 6th Edition, Page No: 268
    • Nerve Supply of Tongue:
    • Motor Nerves:
    • • All the intrinsic and extrinsic muscles, except the palatoglossus, are supplied by the hypoglossal nerve.
    • • The palatoglossus is supplied by the cranial root of the accessory nerve through the pharyngeal plexus.
    • • So seven out of eight muscles are supplied by XII nerve.
    • Sensory Nerves:
    • • The lingual nerve is the nerve of general sensation and the chorda tympani is the nerve of taste for the anterior two-thirds of the tongue except vallate papillae.
    • • The glossopharyngeal nerve is the nerve for both general sensation and taste for the posterior one-third of the tongue including the circumvallate papillae.
    • • The posteriormost part of the tongue is supplied by the vagus nerve through the internal laryngeal branch.

    • Winners:
    • Fastest correct answer respondnets:
    • - Dr Kismat Gurung
    • - Dr Dinesh Neupane

    • Lucky draw winners:
    • - Dr Sudip Niroula
    • - Dr Dinesh Gupta

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to CEE MD/MS Based Model test of Asoj 10 (Saturday, 11:00 AM).
  61. 61
    • 1. Which of the following cannot be a step to handle the angry patient?
    • a. Keep your perspective straight
    • b. Assess your safety
    • c. Get to the real source of concern
    • d. Retaliate their words

    • Ans: d
    • Handling angry patients:
    •  Keep your perspective straight. The anger usually isn’t about you — even if the patient believes it is.
    •  Assess your safety. Do you need a witness? Should you leave the door open? Is this a matter best handled by security or the police?
    •  If at all possible, sit. Sitting tells the patient you have all the time in the world to solve this problem (although we all know you do not).
    •  Acknowledge the anger. “I feel like you are angry,” is an honest way to start the conversation. Alternatively, “I feel our communication has broken down” can help the patient feel heard and steer the conversation toward resolution and not just go-nowhere venting.
    •  Get to the real source of concern. Did the nurse have to stick the patient three times for venous access? Is she afraid she will die? Probe gently but persistently to get to the core issue.
    •  Then, stay silent and listen. The complaint may be 100 percent valid, completely insane, or — more likely — somewhere in between. But you won’t know unless you let the patient talk.
    •  Ask what he would like for you to do; then negotiate. If he demands high-dose narcotics, offer him a milder analgesic that makes you more comfortable. If he demands instant test results, offer to call and find out when the final report may be available. Don’t do anything medically unreasonable or inappropriate. You are, after all, the doctor.
    •  Offer an alternative outlet. Depending on the issue, you may not be the appropriate person to resolve your patient’s anger. The office manager can often help the patient feel her concerns are being addressed.
    •  Once again, remember that the anger isn’t about you…most of the time anyway.

    • 2. Which of the following is true about fetal and neonatal RBCs when compared to adult RBCs?
    • a. RBCs have shorter half live and lower mean corpuscular volume
    • b. RBCs have longer half live and lower mean corpuscular volume
    • c. RBCs have shorter half live and higher mean corpuscular volume
    • d. RBCs have longer half live and higher mean corpuscular volume

    • Ans: c
    • Ref, Nelson, Essentials of pediatrics, 8th edition, Page no. 247
    • After birth, hemoglobin levels increase transiently at 6-12 hours, then decline to 11-12 g/dL at 3 6 months. A premature infant (<32 weeks’ gestational age) has a lower hemoglobin concentration and a more rapid postnatal decline of hemoglobin level, which achieves a nadir 1-2 months after birth. Fetal and neonatal RBCs have a shorter life span (70-90 days) and a higher mean corpuscular volume (110-120 fL) than adult cells. In the fetus, hemoglobin synthesis in the last two trimesters of pregnancy produces fetal hemoglobin (hemoglobin F), composed of two alpha chains and two gamma chains. Immediately before term, the infant begins to synthesize beta-hemoglobin chains; the term infant should have some adult hemoglobin (two alpha chains and two beta chains). Fetal hemoglobin represents 60-90% of hemoglobin at term birth. The levels decline to adult levels of less than 5% by 4 months of age.

    • 3. Types of drugs most likely to be involved in clinically important drug interactions are all except:
    • a. Drugs with broad safety margin
    • b. Drugs affecting closely regulated body functions
    • c. Highly plasma protein bound drugs
    • d. Drugs metabolized by saturation kinetics.

    • Ans: a
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 8th Edition, Page No: 988
    • Types of drugs most likely involved in clinically important drug interactions are:
    • • Drugs with narrow safety margin: aminoglycoside antibiotics, digoxin, lithium.
    • • Drugs affecting closely regulated body functions: antihypertensives, antidiabetic, anticoagulants
    • • Highly plasma protein bound drugs: NSAIDs, oral anticoagulants, sulfonylureas
    • • Drugs metabolized by saturation kinetics: Phenytoin, theophylline

    • 4. Which of the following part of the brain is responsible for acquisition and maintenance of habit and skill learning?
    • a. Hippocampus
    • b. Amygdala
    • c. Caudate nucleus
    • d. Mamillary bodies

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2714, 2715
    • The anatomy of obsessive-compulsive behavior is thought to include the orbital frontal cortex, caudate nucleus, and globus pallidus. The caudate nucleus appears to be involved in the acquisition and maintenance of habit and skill learning, and interventions that are successful in reducing obsessive-compulsive behaviors also decrease metabolic activity measured in the caudate.

    • 5. A 10 years female presents with pain in the right hypochondrium, fever, jaundice and a palpable mass in the right hypochondrium the probable diagnosis is:
    • a. Hepatitis
    • b. Hepatoma
    • c. Choledochal cyst
    • d. Mucocele gallbladder

    • Ans: c
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 1197
    • CHOLEDOCHAL CYST
    • • Cystic disease of the biliary system is rare.
    • • Choledochal cysts are congenital dilations of the intra and/or extrahepatic biliary system. The pathogenesis is unclear.
    • • Anomalous junctions of the biliary pancreatic junction are frequently observed, but whether or not these play a role in the pathogenesis of the condition is unclear.
    • • Todani and colleagues proposed a classification of cystic disease of the biliary tract.
    • • Type I cysts are the most common and account for approximately 75% of patients.
  62. 62
    • 1. What is not used to calculate the revised Baux Score to predict mortality after burn injury?
    • a. Age of patient
    • b. Depth of burn injury
    • c. Inhalational injury
    • d. Total body surface area of burn injury

    • Ans: b
    • Ref: Schwartz’s Surgery, 11th edition, page 254
    •  The Baux score (mortality risk equals age plus %TBSA) was used for many years to predict mortality in burns. Analysis of multiple risk factors for burn mortality has validated age and burn size as the strongest predictors of mortality.
    •  Advancements in burn care have lowered overall mortality to the point that the original Baux score may no longer be accurate. However, the Revised Baux Score, which accounts for age, burn size, and inhalation injury, has been found to be independently associated with mortality.
    •  As such, age, burn size, and inhalation injury continue to be the most robust indicators for burn mortality.

    • 2. Gold standard study for clinical research is
    • a. Randomized double-blind trial
    • b. Systematic meta-analysis
    • c. Ecological study
    • d. Retrospective cohort study

    • Ans: b
    • EVIDENCE-PYRAMID IN RESEARCH: [From top to bottom]
    •  Meta-analysis (Highest clinical relevance: GOLD STANDARD)
    •  Systematic review
    •  Cohort study
    •  Case control study
    •  Case series
    •  Case report
    •  Ideas, Editorials, Opinions
    •  Animal research
    •  In-vitro (test-tube) research (Lowest clinical relevance)

    • 3. Which of the following amino acids does not contain hydroxyl (OH ) group?
    • a. Serine
    • b. Threonine
    • c. Tyrosine
    • d. Tryptophan

    • Ans: d
    • Ref: Satyanarayan Biochemistry, 3rd edition, Page No: 37
    • • Amino acids with aliphatic side chains : glycine, alanine, valine, leucine and Isoleucine
    • • Hydroxyl group containing amino acids : Serine, threonine and tyrosine
    • • Sulfur containing amino acids :Cysteine and Methionine
    • • Acidic amino acids and their amides : Aspartic acid and glutamic acids
    • • Basic amino acids : lysine, arginine and histidine
    • • Aromatic amino acids : Phenylalanine, tyrosine and tryptophan
    • • lmino acids : Proline

    • 4. Damage to pneumotaxic center will cause:
    • a. Apneusis
    • b. Apnea
    • c. Greater Tidal volume with slow breathing
    • d. Small Tidal volume with fast breathing

    • Ans: c
    • Ref: Ganong Review of Medical Physiology, Lange; 25th Edition, Page No: 656
    • Although the rhythmic discharge of medullary neurons concerned with respiration is spontaneous, it is modified by neurons in the pons and afferents in the vagus from receptors in the airways and lungs. An area known as the pneumotaxic center in the medial parabrachial and Kölliker-Fuse nuclei of the dorsolateral pons contains neurons active during inspiration and neurons active during expiration. When this area is damaged, respiration becomes slower and tidal volume greater, and when the vagi are also cut in anesthetized animals, there are prolonged inspiratory spasms that resemble breath holding (apneusis) ; The normal function of the pneumotaxic center is unknown, but it may play a role in switching between inspiration and expiration.
  63. 63
    • 1. A 57-year-old male is admitted to the emergency department after he was struck by a truck while crossing a busy street. Radiographic examination reveals flail chest. During physical examination the patient complains of severe pain during inspiration and expiration. Which of the following nerves is most likely responsible for the sensation of pain during respiration?
    • a. Phrenic
    • b. Vagus
    • c. Cardiopulmonary
    • d. Intercostal

    • Ans: d
    • Ref: Gray’s Anatomy for Students, 213-214
    • Flail chest is characterized by paradoxical breathing movements caused by multiple rib fractures. The sensory innervation provided to intercostal spaces and to the underlying parietal pleura is supplied via the corresponding intercostal nerves. The phrenic nerve provides motor innervation to the diaphragm and sensory innervation to the diaphragmatic and mediastinal parietal pleura and pericardium. The vagus nerves provide parasympathetic innervation to the thoracic viscera, and to the gastrointestinal tract as distal as the left colic flexure. The cardiopulmonary nerves carry sympathetic innervation from T1 to T4 levels to the thoracic organs, and pain fibers from these organs. Thoracic splanchnic nerves carry sympathetic innervation to the abdomen.

    • 2. A patient was referred to your center for the management of eclampsia. She had been started on magnesium sulfate. At what serum level of magnesium does deep tendon reflex disappear?
    • a. >5 mEq/L
    • b. >7 mEq/L
    • c. >10 mEq/L
    • d. >12 mEq/L

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 273
    • • The therapeutic level of serum magnesium is 4–7 mEQ/L.
    • • Serum magnesium levels may be monitored in selected cases (renal insufficiency, absent deep tendon reflexes).
    • • To control fits, optimum serum magnesium level is 4.8–8.4 mg/dL (4-7 mEq/L) to be maintained.

    • Magnesium toxicity and serum Mg level is seen as:
    • • loss of deep tendon reflexes > 7 mEq/L;
    • • respiratory depression more than 10 mEq/L and
    • • cardiac arrest more than 25 mEq/L.
    • Magnesium sulfate is continued for 24 hours after the last seizure or delivery whichever is later.

    • 3. A 3 days old child born in the periphery presented to you. You diagnose the case as club foot and start explaining the condition to the parents. You suggest the Ponseti treatment modality. Parents enquire how many different casts are usually needed in an average to correct the deformity, you answer?
    • a. 2
    • b. 5
    • c. 8
    • d. 12

    • Ans: b
    • Ref: Apley & Solomon’s System of Orthopaedics & Trauma, 10th edition, page 615
    •  Conservative treatment of talipes equinovarus (idiopathic club foot) should begin early, preferably within the first 2 weeks after birth. This consists of manipulation repeated weekly, with the foot held in place with a plaster cast.
    •  The three main components of the deformity are corrected in the following order. Firstly, the first metatarsal is elevated to correct the cavus and create a flat longitudinal medial border of the foot.
    •  Next, the forefoot is abducted in the plane of the metatarsals which rotates and everts the hindfoot and corrects the forefoot out of supination. This manoeuvre will also result in dorsiflexion of the os calcis as it rotates from underneath the talus.
    •  Finally, equinus is corrected by dorsiflexing the foot at the ankle joint. It is necessary in approximately 85% of cases to perform a percutaneous Achilles tenotomy in order to fully correct the equinus.
    •  Correction will typically require an average of five casts and, once corrected, the foot is retained in a further cast for 3 weeks. Following the complete correction of the club foot by serial casting, the deformity must be held using a foot abduction brace (FAB) to prevent relapse. This is retained for 3 months fulltime (23 hours per day) and then night-time and nap-time for 4 years.

    • 4. A 32-year-old patient received a badly placed intramuscular injection to the posterior part of his gluteal region. The needle injured a motor nerve in the area. Later, he had great difficulty rising to a standing position from a seated position. Which muscle was most likely affected by the injury?
    • a. Gluteus maximus
    • b. Gluteus minimus
    • c. Hamstrings
    • d. Iliopsoas

    • Ans: a
    • The gluteus maximus is innervated by the inferior gluteal nerve, and this muscle is responsible for extension and lateral rotation of the thigh. It is the primary muscle used to rise from a seated position. The gluteus minimus is innervated by the superior gluteal nerve and is responsible for abduction of the thigh. Hamstring muscles are innervated by the tibial portion of the sciatic nerve, and these are responsible for extension of the thigh and flexion of the leg. The iliopsoas muscle is innervated by L1 and L2 and the femoral nerve, and it fl exes the thigh. The obturator internus is innervated by the nerve to the obturator internus and is a lateral rotator of the thigh.
  64. 64
    Get opportunity to get one set free on ASHOJ 23. Answer these three question.We will choose randomy 3 candidates tomorrow morning.

    • 1. Which nerve is not involved in olfaction:
    • A) Trigeminal
    • B) Glossopharyngeal
    • C) Vagus
    • D) Hypoglossal

    Ans : D

    • 2.What will be the GCS score for a patient who is intubated and is opening eyes on command
    • and there are movement of all 4 limbs on command?
    • A) 10
    • B) 12
    • C) 9
    • D) 11

    Ans : C

    • 3.Intake of which drug during last trimester causes Unconjugated Bilirubinemia in infant?
    • A) Cotrimoxazole
    • B) Chloroquine
    • C) Azithromycin
    • D) chloramphenicol

    Ans : A

    ANSWER IS

    • 1. Answer: D) Hypoglossal
    • Hypoglossal nerve is the 12th cranial nerve and originates from the medulla oblongata. It is a pure
    • motor nerve
    • ● Hypoglossal nerve is a motor nerve which, involved in the movement of tongue muscles,
    • swallowing and speech.
    • ● It innervates all the muscles of the tongue except palatoglossus muscle which is innervated by
    • the vagus nerve.

    • 2. Answer C) 9
    • Explanation- GCS score is E3 VT M6 = 9T/10 or 9/ 10 + V =nt

    • 3. Ans. A.Cotrimoxazole
    • Cotrimoxazole is not used in the first three months of pregnancy (first trimester) because of the risk it poses to the development of the foetus.It can, however, be used after three months of pregnancy, but should be avoided in the last three
    • months (third trimester) because it is known to cause a breakdown of the red blood cells of the foetus.
  65. 65
    Answers and Winners of QUIZ for Subjectwise (MEDICINE) MD/MS Based Online Model Test [07:00 PM, Asoj 26, 2077, Monday]

    • 1. A 68 year old male presented with chest pain and dyspnea. Pulsus tardus is seen. Diagnosis is:
    • a. Mitral stenosis
    • b. Aortic valve stenosis
    • c. Aortic regurgitation
    • d. Mitral regurgitation

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1445
    • • The character of the pulse is best appreciated at the carotid level.
    • • A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic stenosis (AS). Some patients with AS may also have a slow, notched, or interrupted upstroke (anacrotic pulse) with a thrill or shudder.
    • • With chronic severe AR, by contrast, the carotid upstroke has a sharp rise and rapid fall-off (Corrigan’s or water-hammer pulse).
    • • Some patients with advanced AR may have a bifid or bisferiens pulse, in which two systolic peaks can be appreciated.
    • • A bifid pulse is also described in patients with hypertrophic obstructive cardiomyopathy (HOCM), with inscription of percussion and tidal waves. A bifid pulse is easily appreciated in patients on intraaortic balloon counterpulsation (IABP), in whom the second pulse is diastolic in timing.

    • 2. In severe hyperkalemia, 10 mL of 10% calcium gluconate should be infused over?
    • a. Half to 1 minute
    • b. 1 to 2 minutes
    • c. 2 to 3 minutes
    • d. 5 to 10 minutes

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 17th Edition, Page No: 284
    • IV Calcium gluconate decreases membrane excitability. Usual dose is 10 mL of a 10% solution infused over 2-3 minutes. Its effect is short-lived (30-60 min). Dose can be repeated if no change in ECG is seen after 5-10 minutes.

    • 3. A person presented to OPD with complaints of blood on coughing. Which of the following is the most common cause of hemoptysis worldwide?
    • a. Bacterial pneumonia
    • b. Tuberculosis
    • c. Malignancy
    • d. Chronic bronchitis

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 323
    • Hemoptysis, the expectoration of blood from the respiratory tract, can arise at any location from the alveoli to the glottis
    • Worldwide, the most common cause of hemoptysis is infection with Mycobacterium tuberculosis, presumably because of the high prevalence of tuberculosis and its predilection for cavity formation.

    • 4. Positive urine anion gap is seen in which one of the following?
    • a. Acute Diarrhea
    • b. Vomiting
    • c. Renal tubular Acidosis
    • d. Aspirin Toxicity

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 320
    • The typical findings in acquired or inherited forms of classic distal RTA (type 1 RTA) include hypokalemia, non-AG metabolic acidosis, low urinary NH4+ excretion (positive UAG, low urine [NH4+]), and inappropriately high urine pH (pH > 5.5).
  66. 66
    • 1. Which of the following is the classical feature of cardiac syncope?
    • a. Gradual onset
    • b. Warning symptoms
    • c. Rapid recovery
    • d. Residual neurological deficit

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 142
    • The causes of syncope can be divided into three general categories: (1) neutrally mediated syncope (also called reflex or vasovagal syncope), (2) orthostatic hypotension, and (3) cardiac syncope.
    • Cardiovascular disorders produce dizziness and syncope by transient hypotension, resulting in abrupt cerebral hypoperfusion. For this reason, patients who experience cardiac syncope usually describe either brief lightheadedness or no warning symptoms at all prior to their syncopal attacks. Recovery is usually rapid, unlike with other common causes of syncope (e.g. stroke, epilepsy, overdose).
    • Postural hypotension:
    • Syncope on standing upright reflects inadequate baroreceptor-mediated vasoconstriction. It is common in the elderly in whom it is frequently compounded by medication. Abrupt reductions in blood pressure and cerebral perfusion cause the patient to fall to the ground, whereupon the condition corrects itself.
    • Vasovagal syncope
    • This is caused by autonomic overactivity, usually provoked by emotional or painful stimuli, less commonly by coughing or micturition (‘cough syncope’ or ‘micturition syncope’). Only rarely are syncopal attacks so frequent as to be significantly disabling (‘malignant’ vasovagal syndrome). Vasodilatation and inappropriate slowing of the pulse combine to reduce blood pressure and cerebral perfusion. Recovery is rapid if the patient lies down.

    • 2. Which of the following viral infections commonly produces cranial nerve palsies?
    • a. HIV
    • b. HSV
    • c. EBV
    • d. CMV

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 893
    • Cranial nerve palsies, most commonly involving cranial nerves V, VII, or VIII, are more common in HIV meningitis than in other viral infections.
    • Diagnosis can be confirmed by detection of HIV genome in blood or CSF. Seroconversion may be delayed, and patients with negative HIV serologies who are suspected of having HIV meningitis should be monitored for delayed seroconversion.

    • 3. Triad of skin lesions, asymmetric mononeuritis multiplex and eosinophilia are seen in?
    • a. Cryoglobulinemic vasculitis
    • b. Polyarteritis nodosa
    • c. Churg Strauss Syndrome
    • d. Giant cell arteritis

    • Ans: c
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1840
    • Churg-Strauss Syndrome When small-vessel vasculitis is associated with peripheral eosinophilia, cutaneous purpura, mononeuritis, asthma, and allergic rhinitis, a diagnosis of Churg-Strauss syndrome is considered.
    • Churg Strauss Syndrome
    • • Churg Strauss Syndrome is a small vessel vasculitis.
    • • Biopsy of affected site reveals small vessel vasculitis with eosinophilic infiltration of vessel wall.
    • Cryoglobulinemic vasculitis
    • • Cryoglobulinemic vasculitis presents with rash over lower limbs, arthralgia, Raynaud’s phenomenon and neuropathy
    • Polyarteritis nodosa
    • • Polyarteritis nodosa presents with fever, myalgia, arthralgia, multisystem involvement and palpable purpura.
    • Giant cell arteritis
    • • Cardinal symptom of giant cell arteritis is headache localised to temporal or occipital region.
    • • Visual disturbances can occur.
    • • Catastrophic presentation is with blindness in one eye.
    • • It is commonly associated with polymyalgia rheumatica.

    • 4. A person on medical examination before international travel was found to be infected with hepatitis B .Which of the following is true regarding hepatitis B infection and laboratory tests?
    • a. ALT>AST in acute hepatitis B
    • b. AST>ALT in chronic hepatitis B
    • c. Both a and b
    • d. Hyperglobulinemia is a feature of chronic hepatitis B

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2685
    • • Laboratory features of chronic hepatitis B do not distinguish adequately between histologically mild and severe hepatitis.
    • • Aminotransferase elevations tend to be modest for chronic hepatitis B but may fluctuate in the range of 100-1000 units. As is true for acute viral hepatitis B, alanine aminotransferase (AL T) tends to be more elevated than aspartate aminotransferase (AST); however, once cirrhosis is established, AST tends to exceed ALT. Levels of alkaline phosphatase activity tend to be normal or only marginally elevated. In severe cases moderate elevations in serum bilirubin [3一10 mg/dL] occur.
    • • Hypoalbuminemia and prolongation of the prothrombin time occur in severe or end-stage cases. Hyperglobulinemia and detectable circulating autoantibodies are distinctly absent in chronic hepatitis B (in contrast to autoimmune hepatitis).
  67. 67
    Answers and Winners of QUIZ for Today evening CEE MD/MS Based Online Model Test [07:00 PM, Mangsir 10, 2077, Wednesday].

    • 1. Partial agonist possesses:
    • a. Max. intrinsic activity and low affinity
    • b. High intrinsic activity and no affinity
    • c. Low intrinsic activity and high affinity
    • d. Low intrinsic activity and low affinity

    • Ans: c
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 7th Edition, Page No: 42
    • • Agonists have both affinity and maximal intrinsic activity (IA = 1), e.g. adrenaline, histamine, morphine.
    • • Competitive antagonists have affinity but no intrinsic activity (IA = 0), e.g. propranolol, atropine, chlorpheniramine, naloxone.
    • • Partial agonists have affinity and submaximal intrinsic activity (IA between 0 and 1), e.g. dichloroisoproterenol (on β adrenergic receptor), pentazocine (on μ opioid receptor).
    • • Inverse agonists have affinity but intrinsic activity with a minus sign (IA between 0 and –1), e.g. DMCM (on benzodiazepine receptor), chlorpheniramine (on H1 histamine receptor).
    • • It has also been demonstrated that many full agonists can produce maximal response even while occupying <1% of the available receptors. A large receptor reserve exists in their case, or a number of spare receptors are present.

    • 2. The Milwaukee brace is used for correction of:
    • a. Congenital dislocation of the hip
    • b. Club foot
    • c. Scoliosis
    • d. Patella alta

    • Ans: c
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 282
    • • The Milwaukee brace is an active corrective spinal orthosis used almost exclusively in the ambulant treatment of structural scoliosis the aim being to postpone temporarily or permanently the need for operation.
    • • It frequently has to be worn for a number of years until the spine is stable.

    • 3. Ewing’s sarcoma is associated with translocation between which chromosomes?
    • a. 21 and 11
    • b. 21 and 12
    • c. 22 and 11
    • d. 22 and 12

    • Ans: c
    • Ref: Apley & Solomon’s System of Orthopaedics & Trauma, 10th edition, page 179
    •  In the case of Ewing’s sarcoma, more than 95% of tumours demonstrate EWS-ETSfusion gene rearrangements, most commonly the result of translocations between chromosome 22 and chromosome 11 (t22;11(q24;q12) translocation) or 21 (t21;22(q22;q12)).
    •  The ETS transcription factor family is responsible for regulating cellular differentiation, the cell cycle, cell migration and apoptosis. Therefore mutations will result in deregulation of programmed cell death and disruption of cell-cycle control.

    • 4. Normal distribution curve is determined by:
    • a. Standard deviation and mean
    • b. Standard deviation and mode
    • c. Mode and median
    • d. Standard deviation and median

    • Ans: a
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 102
    • The characteristics of a normal curve are:
    •  It is bell-shaped or like breast.
    •  It is symmetrical.
    •  Mean, mode and median coincide.
    •  50% of all values lie above Mean (or Median or Mode)
    •  It has two inflections. The central part is convex while and the points of inflection, the curve changes from convexity to concavity. A perpendicular from the point of inflection will cut the base at a distance of one SD from the mean on either side.
    •  Mean ± 1SD cover 68% values (Mean + 1SD cover 34% values)
    •  Mean ± 2SD cover 95% values (Mean + 2SD cover 47.5% values)
    •  Mean ± 3SD cover 99% values (Mean + 3SD cover 49.5% values)
  68. 68
    • 1. Patient counselling should be done by:
    • a. Treating physician
    • b. Nursing staff who takes care
    • c. Health administrator
    • d. Junior doctor who attends round

    • Ans: a
    • Communication is the transfer of information meaningful to those involved. It is the process in which messages are generated and sent by one person and received and translated by another person. However, the meaning generated by the receiver can be different from the sender’s intended message.
    • The communication process between health professionals and patients serves two primary functions.
    •  It establishes an ongoing relationship between the professional and the patient.
    •  It provides the exchange of information necessary to assess a patient’s health condition, implement treatment of medical problems, and evaluate the effects of treatment on a patient’s quality of life.
    • The healthcare professional must be able to
    • - understand the illness experience of the patient
    • - perceive each patient’s experience as unique
    • - foster a more egalitarian relationship with patients
    • - build a therapeutic alliance with patients to meet mutually understood goals of therapy
    • - develop self-awareness of personal effects on patients

    • The healthcare professional should encourage patients to share experiences with therapy
    • because
    • - they have unanswered questions
    • - they have misunderstandings
    • - they experience problems to therapy
    • - they can “monitor” their own responses to treatment
    • - they make their own decisions regarding therapy
    • - they may not reveal information to you unless you initiate a dialogue
    • Communication during drug therapy
    • - Purpose of medication
    • - How medication works
    • - Dose and duration of therapy
    • - Goals of therapy
    • - How effectiveness will be monitored
    • - Adverse effects and how to deal with them
    • - Drug specific issues

    • 2. Agnes hunt traction is used for:
    • a. Open forearm fracture
    • b. Scoliosis
    • c. Trochanteric traction
    • d. Correction of hip deformity

    • Ans: D
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 27
    • Traction systems and their uses
    • • Gallow's traction Fracture shaft of the femur in children below 2 years
    • • Bryant's traction Fracture shaft of the femur in children below 2 years
    • • Russell's traction Trochanteric fractures
    • • Buck's traction Conventional skin traction
    • • Perkin's traction Fracture shaft of femur in adults
    • • 90°-90° traction Fracture shaft of femur in children
    • • Agnes-Hunt traction Correction of hip deformity
    • • Well-leg traction Correction of adduction or abduction deformity of hip
    • • Dunlop traction Supracondylar fracture of humerus
    • • Smith's traction Supracondylar fracture of humerus
    • • Calcaneal traction Open fractures of ankle or leg
    • • Metacarpal traction Open forearm fractures
    • • Head-halter traction Cervical spine injuries
    • • Crutchfield traction Cervical spine injuries
    • • Halo-pelvic traction Scoliosis

    • 3. Most common acute complication of hemodialysis is?
    • a. Infection
    • b. Hypotension
    • c. Anemia
    • d. Anaphylactoid reactions

    • Ans: B
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1824
    • • Hypotension is the most common acute complication of hemodialysis, particularly among patients with diabetes mellitus.
    • • Numerous factors appear to increase the risk of hypotension, including excessive ultrafiltration with inadequate compensatory vascular filling, impaired vasoactive or autonomic responses, osmolar shifts, overzealous use of antihypertensive agents, and reduced cardiac reserve.

    • 4. MEN II is seen with which of the following thyroid carcinoma:
    • a. Follicular
    • b. Anaplastic
    • c. Medullary
    • d. Papillary

    • Ans: c
    • Ref: Sabiston Surgery 20th Edition, Page No: 1004
    • MEN IIa or SIPPLE'S SYNDROME consists of pheochromocytoma (tumors of adrenal medulla) with medullary carcinoma thyroid associated with adenoma or hyperplasia of parathyroid glands.

    • 5. The following statements are related to occipitoposterior except:
    • a. Malrotation of occiput my cause occipitosacral arrest
    • b. 10% cases are associated with anthropoid or android pelvis
    • c. Incomplete forward rotation of occiput may cause deep transverse arrest
    • d. Nonrotation of occiput may cause oblique posterior arrest

    • Ans: b
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 424
    • • Occiput-posterior is an abnormal position of the vertex rather than an abnormal presentation.
    • • In more than 50%, the occipitoposterior position is associated with either an anthropoid or android pelvis.
    • • Incomplete forward rotation: In this condition, the occiput rotates through 1/8th of a circle anteriorly and the sagittal suture comes to lie in the bispinous diameter. Thereafter, further anterior rotation is unlikely and arrest in this position is called deep transverse arrest.
    • • Nonrotation: Both the sinciput and the occiput touch the pelvic floor simultaneously due to moderate deflexion of the head resulting in nonrotation of the occiput. The sagittal suture lies in the oblique diameter. Further mechanism is unlikely and the condition is called oblique posterior arrest.
    • • Malrotation: In extreme deflexion, the sinciput touches the pelvic floor first resulting in anterior rotation of the sinciput to 1/8th of a circle and putting the occiput to the sacral hollow. Th is position is termed as occipitosacral position.
  69. 69
    • 1. Histogram is used to describe:
    • a. Quantitative data of a group of patients
    • b. Qualitative data of a group of patients
    • c. Data collected on nominal scale
    • d. Data collected on ordinal scale

    • Ans: a
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 845
    • Data presentation:
    • Quantitative data
    • • Histogram
    • • Frequency polygon
    • • Frequency curve
    • • Line chart/ graph
    • • Cumulative frequency diagram (Ogive)
    • • Scatter/ Dot diagram
    • Qualitative data
    • • Bar diagram
    • • Pie/Sector diagram
    • • Pictogram/Picture diagram
    • • Map diagram/Spot map

    • 2. L-asparaginase is used in treatment of which type of leukemia?
    • a. ALL
    • b. AML
    • c. CLL
    • d. AML

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 760
    • Treatment in adult patients with acute lymphoblastic leukemia (ALL):
    •  Pediatric-Inspired Therapies Pediatric-inspired therapies for adolescents and young adults provide increased drug intensity at several stages of treatment, including larger cumulative doses of drugs such as glucocorticoids, vincristine, L-asparaginase, and consequent central nervous system-directed therapy, which should be strictly adhered to, thereby reducing the role of stem cell transplant in such cases. In a 2012 meta-analysis of 11 trials, including 2489 adolescents and young adults, pediatric-inspired regimens were superior to conventional adult chemotherapy. However, none of the trials was a randomized comparison. Table 102-4 gives the outcome of recent studies with pediatric-inspired regimens for adolescents and young adults with a median age of 27 years. The complete remission rate was very high with 93% (85–98%), and the overall survival rate of 70% (60–78%) was very encouraging. Survival rates at ≥5 years were 70% (67–78%) compared to 34–41% with the former protocols.
    •  Adult ALL The treatment results for adult ALL patients have moderately improved (Table 102-4). The overall survival is 36% with a wide variation from 27 to 60% due to differences in the intensity of the chemotherapy regimen and the outcome of stem cell transplantation.In several current multicenter prospective trials, the overall survival rate for standard-risk adult ALL patients is now 50–70% with chemo therapy alone. Overall survival for high-risk patients increased from 20–30% to >50% when they received an allogeneic stem cell transplant in first complete remission.
    •  Elderly ALL Since palliative treatments or intensive chemotherapy regimens have failed, with either low complete remission rates or high early death rates, short elderly specific ALL protocols have been initiated, with less intensive therapy (avoiding anthracyclines and alkylating agents). With these protocols, the complete remission rate was increased to 73%, early death could be reduced to 13% (0–36%), and overall survival was 42%.

    • 3. The term Point blank is used in:
    • a. Ballistics
    • b. Hematinics
    • c. Autopsy
    • d. Torture

    • Ans: a
    • Ref: Reddy Forensic Medicine, 33rd Edition, Page No: 222, 223
    • Close Shot:
    • • This term is applied when the victim is within the range of the flame, i.e., 5 to 8 cm.
    • • The term 'point blank' is used when the range is very close to or in contact with the surface of the skin.
    • • The entrance wound is circular with inverted edges, but the rebounding gases may level up or even evert the margins.
    • • The skin is burnt with singeing of the hair.
    • • The skin surrounding the wound is hyperaemic and shows some bruising, burning, blackening and tattooing.

    • 4. 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’s Principles of Internal Medicine; 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.

    • 5. Defective DNA repair is associated with:
    • a. Xeroderma pigmentosum
    • b. Albinism
    • c. Ichthyosis
    • d. Vitiligo

    • Ans: a
    • Xeroderma Pigmentosum
    • • The basic defect in xeroderma pigmentosum is in nucleotide excision repair (NER), leading to deficient repair of DNA damaged by UV radiation.
    • • This extensively studied process consists of the removal and the replacement of damaged DNA with new DNA.
    • • Two types of NER exist: global genome (GG-NER) and transcription coupled (TC-NER).
    • • The last decade has seen the cloning of the key elements of NER, and the process has been reconstituted in vitro.
    • • In addition to the defects in the repair genes, UV-B radiation also has immunosuppressive effects that may be involved in the pathogenesis of xeroderma pigmentosum. Although typical symptoms of immune deficiency, such as multiple infections, are not usually observed in patients with xeroderma pigmentosum, several immunologic abnormalities have been described in the skin of patients with xeroderma pigmentosum.
    • • Clinical studies of the skin of patients with xeroderma pigmentosum indicate prominent depletion of Langerhans cells induced by UV radiation.
    • • Various other defects in cell-mediated immunity have been reported in xeroderma pigmentosum.
    • • These defects include impaired cutaneous responses to recall antigens, decreased ratio of circulating T-helper cells to suppressor cells, impaired lymphocyte proliferative responses to mitogen, impaired production of interferon in lymphocytes, and reduced natural killer cell activity.
    • • At birth the skin is normal. First thing to appear is freckles on sun exposed area. By the age of 20, various benign and malignant tumors develop. Associated features are ocular lesions like photophobia, conjunctivitis and various neurological complications.
  70. 70
    • 1. Bimalleolar fracture is called:
    • a. Pott's fracture
    • b. Massonaives fracture
    • c. Chopart’s fracture
    • d. Jane's fracture

    • Ans: A
    • Ref: Ebnezar Orthopedics 4th Edition, Page No: 879
    • • Jones’ fracture Avulsion fracture of the base of 5th metatarsal
    • • Chopart dislocation A fracture through inter tarsal joints
    • • Massonaises fracture It is a type of ankle fracture in which fracture of the neck of the fibula occurs
    • • Pott’s fracture Bimalleolar ankle fracture
    • • March fracture: Shaft of 2nd or 3rd metatarsal

    • 2. Pegloticase is useful in which condition?
    • a. Hypercalcemia
    • b. Hyperkalemia
    • c. Hypernatremia
    • d. Hyperuricemia

    • Ans: d
    • Ref: Katzung’s Basic & Clinical Pharmacology; Lange; 14th Edition, Page No: 663
    • • Pegloticase is the newest urate-lowering therapy to be approved for the treatment of refractory chronic gout.
    • • It is a recombinant mammalian uricase that is covalently attached to methoxy polyethylene glycol (mPEG) to prolong the circulating half-life and diminish immunogenic response.
    • • The recommended dose for pegloticase is 8 mg every 2 weeks administered as an intravenous infusion. It is a rapidly acting drug, achieving a peak decline in uric acid level within 24–72 hours. The serum halflife ranges from 6 to 14 days. Several studies have shown earlier clearance of PEG-uricase (mean of 11 days) due to antibody response when compared to PEG-uricase antibody-negative subjects (mean of 16.1 days).
    • • Urate oxidase enzyme, absent in humans and some higher primates, converts uric acid to allantoin. This product is highly soluble and can be easily eliminated by the kidney. Pegloticase has been shown to maintain low urate levels for up to 21 days after a single dose at doses of 4–12 mg, allowing for IV dosing every 2 weeks. Pegloticase should not be used for asymptomatic hyperuricemia.

    • 3. A screening test was positive in 50% of diseased and 10% of healthy population What is the specificity of the test?
    • a. 0.5
    • b. 0.9
    • c. 0.83
    • d. 0.064

    • Ans: b
    • • Sensitivity: Ability of a screening test to identify correctly all those who have the disease (cases)
    • Sensitivity = a/ (a + c) x 100 = TP/ (TP + FN) x 100
    • • Specificity: Ability of a screening test to identify correctly all those who do not have the disease (healthy)
    • Specificity = d/ (b + d) x 100 = TN/ (TN + FP) x 100
    • • Positive predictive value (PPV): Ability of a screening test to identify correctly all those who have the disease, out of all those who test positive on a screening test
    • PPV = a/ (a + b) x 100 = TP/(TP + FP) x 100
    • • Negative predictive value (NPV): Ability of a screening test to identify correctly all those who do not have the disease, out of all those who test negative on a screening test
    • NPV = d/ (c + d) x 100 = TN/ (FN + TN) x 100

    • 4. Mother friendly childbirth initiative was launched in:
    • a. Nepal
    • b. Sudan
    • c. Australia
    • d. USA

    • Ans: d
    • Mother friendly childbirth initiative (MFCI)
    • To improve care throughout the childbearing continuum in order to save lives, prevent illness and harm from the overuse of obstetric technologies, and promote health for mothers and babies around the world.
    • Launched: 1996, USA

    • 5. Which anatomical finding best describes nutcracker syndrome?
    • a. Superior mesenteric artery compress transverse portion of duodenum.
    • b. Aorta compresses transverse portion of duodenum.
    • c. Superior mesenteric artery and aorta compress left renal vein between them.
    • d. Superior mesenteric artery and aorta compress right renal vein between them.

    • Ans: c
    • Ref: USMLE Step 1 First Aid 2020, Page No: 357
    • • Nutcracker syndrome is compression of left renal vein between superior mesenteric artery and aorta. It is characterized by flank pain and gross hematuria (d/t rupture of thin walled renal varicosities)
    • • Superior mesenteric artery syndrome is characterized by intermittent intestinal obstruction symptoms (primarily postprandial pain). It occurs when superior mesenteric artery and aorta compress the transverse (third) part of duodenum. It typically occurs in conditions associated with diminished mesenteric fat (eg, low body weight/malnutrition).
  71. 71
    Answers and Wiiners of QUIZ for Subjectwise [SURGERY & PEDIATRICS] for CEE MD/MS Based Model test of Kartik 3 (Monday, 07:00 PM).

    • 1. A person presented to the Emergency room following trauma to the head. He opens his eyes on verbal command, produces incomprehensible sounds and withdraws from pain. What is his Glasgow Coma Score?
    • a. 6
    • b. 7
    • c. 8
    • d. 9

    • Ans: d
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 325
    • The person in question can:
    • • Open his eyes on verbal command = 3
    • • Produces incomprehensible sounds = 2
    • • Withdraws from pain = 4
    • • Total = 3 + 2+ 4 = 9

    • 2. A 65 year old female presents with a swelling in the neck diagnosed as a solitary thyroid nodule. The patient is investigated and a scan shows increased uptake of iodine. Serum T3 and T4 are elevated. Most probable diagnosis is?
    • a. Benign cold nodule
    • b. Toxic Adenoma
    • c. Follicular adenoma
    • d. Toxic Multinodular goiter

    • Ans: b
    • Ref: Schwartz’s Principles of Surgery, Eleventh Edition, Page No: 1539
    • Elevated thyroid hormone levels with a hyperfunctioning nodule is suggestive of Toxic adenoma.
    • A cold nodule is more likely to be malignant than a hot nodule.

    • 3. Hyperextension of hip producing pain in acute appendicitis is due to which muscle?
    • a. Gluteus maximus
    • b. Obturator Externus
    • c. Psoas Major
    • d. Quadratus lumborum

    • Ans: c
    • Ref: Sabiston Surgery 20th Edition, Page No: 1335
    • Hyperextension of the hip joint may induce abdominal pain, this known as iliopsoas sign and is typical of retrocecal appendicitis.

    • 4. Hernia from lateral boarder of external oblique, latissimus dorsi, and iliac crest is:
    • a. Direct hernia
    • b. Lumbar hernia
    • c. Indirect hernia
    • d. Richter’s hernia

    • Ans: b
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 1042
    • Most primary lumbar hernias occur through the inferior lumbar triangle of Petit bounded below by the crest of the ilium, laterally by the external oblique muscle and medially by latissimus dorsi. Less commonly, the sac comes through the superior lumbar triangle, which is bounded by the twelfth rib above, medially by sacrospinalis and laterally by the posterior border of the internal oblique muscle. Primary lumbar hernias are rare, but may be mimicked by incisional hernias arising through flank incisions for renal operations, or through incisions for bone grafts harvested from the iliac crest.
  72. 72
    Answers and Winners of QUIZ for Subjectwise [SURGERY & PEDIATRICS] for CEE MD/MS Based Model test of Kartik 3 (Monday, 07:00 PM).

    • 1. Renal vein thrombosis is most commonly found in -
    • a. Focal glomerulosclerosis
    • b. Membranous Nephropathy
    • c. Minimal change GN
    • d. Acute pyelonephritis

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 2502
    • Clinical manifestation of Membranous Nephropathy
    • In children, MN is most common in the 2nd decade of life, but it can occur at any age, including infancy. The disease usually manifests as nephrotic syndrome and accounts for 2-6% of all cases of childhood nephrotic syndrome. Most patients also have microscopic hematuria and only rarely present with gross hematuria. Approximately 20% of children have hypertension at presentation. A subset of patients with MN present with a major venous thrombosis, commonly renal vein thrombosis. This well-known complication of nephrotic syndrome is particularly common in patients with MN. Serum C3 and CH50 levels are normal, except in cases of systemic lupus erythematosus, where levels may be depressed.

    • 2. Growth retardation, taste alteration, hepatosplenomegaly, hypochromic microcytic anemia, loss of hair, hypogonadism in a boy indicate deficiency of:
    • a. Selenium
    • b. Copper
    • c. Zinc
    • d. Iron

    • Ans: c
    • Ref: OP Ghai Pediatrics 9th Edition, Page No: 122 | nel 1849
    • Zinc
    • • Zinc is the second most common trace element in the body after iron.
    • • It is an essential micronutrient with diverse but critical physiological role being part of more than 200 enzymatic reactions.
    • • As a component of zinc finger proteins, zinc regulates gene transcription and participates in nucleic acid metabolism, protein synthesis and thereby, cellular growth.
    • • Zinc is a major antioxidant being part of the enzyme superoxide dismutase.
    • Acrodermatitis enteropathica
    • • The congenital form of acrodermatitis enteropathica manifests with severe deficiency of body zinc soon after birth in bottle-fed children or after weaning from breastfeeding.
    • • Clinical signs of this disorder are anorexia, diarrhea, failure to thrive, humoral and cell-mediated immunodeficiency (poor wound healing, recurrent infections), male hypogonadism, skin lesions (vesicobullous dermatitis on the extremities and perirectal, perigenital, and perioral regions, and alopecia), and neurologic abnormalities (tremor, apathy, depression, irritability, nystagmus, photophobia, night blindness, and hypogeusia).

    • 3. Gene of Wilson’s disease is:
    • a. ATP 7A
    • b. ATP7B
    • c. ADP7A
    • d. ADP7B

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1931
    • • ATP7B: ATP7B protein, P-type ATPase; function as copper export pump; Disease: Wilson disease
    • • CLDN1: Claudin 1 protein; Tight junction protein, Disease: neonatal sclerosing cholangitis with ichthyosis
    • • CFTR: CFTR protein, Chloride channel with ATP-binding cassette (ABC family of proteins); regulates chloride transport, Disease: Cystic fibrosis

    • 4. A 10-year-old girl presents with a fever and migrating joint pains in the knees and elbows. She reports having had a sore throat a few days ago. On physical exam, she is febrile and has barely raised erythematous serpentine-like lesions on her back. A rapid streptococcal test is positive and there is an elevated erythrocyte sedimentation rate. She is given antibiotics for this disease. Which is least common valve to be involved in this case?
    • a. Aortic Valve
    • b. Tricuspid Valve
    • c. Mitral Valve
    • d. Pulmonary Valve

    • Ans: d
    • Ref: OP Ghai Pediatrics 9th Edition, Page No: 381
    • Endocarditis in rheumatic fever:
    • - Mitral valve involved almost all the cases of Acute Rheumatic Fever
    • - Almost 25% of MR is associated with aortic regurgitation
    • - Tricuspid Regurgitation is seen in 10-30% cases
    • - Pulmonary valve involvement is never seen

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Sujata Chaudhary
    • - Dr Sarita Ray

    • Lucky draw winners:
    • - Dr Pretty Shrestha
    • - Dr Rajat Acharya

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Subjectwise [SURGERY & PEDIATRICS] for CEE MD/MS Based Model test of Kartik 3 (Monday, 07:00 PM).
  73. 73
    Answrs and Winners of QUIZ for CEE MD/MS Based Online Model Test [07:00 PM, Kartik 5, 2077, Wednesday].

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

    • Ans: a
    • Ref: Ganong Review of Medical Physiology, Lange; 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.

    • 2. When is maximum fetal growth velocity achieved during pregnancy?
    • a. 16 – 20 weeks
    • b. 24 – 28 weeks
    • c. 32 – 36 weeks
    • d. 36 – 40 weeks

    • Ans: c
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 84
    • • Fetal growth velocity is maximum (26.9 g/day) over the 32–36 weeks of pregnancy. It declines gradually to 24 g/day over the 36–40 weeks of gestation. Individual fetal growth varies considerably.
    • • Conditional centiles depending on individual fetal growth velocity is thought to be more important.

    • 3. Which layer of epidermis is thickened to form Wickham striae in lichen planus?
    • a. Corneum
    • b. Granular
    • c. Lucidum
    • d. Spinosum

    • Ans: b
    • Ref: Bolognia Dermatology, 4th edition, page 192
    • • The characteristic primary lesion of Lichen Planus is a small, polygonal-shaped, violaceous, flat-topped papule; occasionally papules are umbilicated.
    • • The surface is slightly shiny or transparent, and a network of fine white lines called “Wickham striae” or small gray–white puncta are also seen. The latter correspond histologically to focal thickening of the granular layer. Wickham striae are readily apparent by dermoscopy.

    • 4. A 40-year-old woman treated for many years for gastroesophageal reflux develops dysphagia and weight loss. Previous esophagoscopy has revealed cellular atypia. An esophagoscopy is about to be performed. What is it most likely to reveal?
    • a. Leiomyoma arising from the long esophageal muscular layer
    • b. Squamous cell carcinoma arising from esophageal mucosal lining
    • c. Adenocarcinoma originated from islands of Barrett’s esophagus
    • d. Adenocarcinoma extending from the stomach

    • Ans: c
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 1082, 1085
    • Adenocarcinoma is originated from islands of Barrett’s esophagus. Intestinal metaplasia is a risk factor for the development of adenocarcinoma.
    • Carcinoma of the oesophagus
    • • Squamous cell usually affects the upper two-thirds; adenocarcinoma usually affects the lower third
    • • Common aetiological factors are tobacco and alcohol (squamous cell), GORD and obesity (adenocarcinoma)
    • • The incidence of adenocarcinoma is increasing
    • • Lymph node involvement is a bad prognostic factor
    • • Dysphagia is the most common presenting symptom, but is a late feature
    • • Accurate pretreatment staging is essential in patients thought to be fit to undergo ‘curative’ treatment

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Sareen Shrestha
    • - Dr Prabhat Rijal
    • - Dr Prabhat KC
    • - Dr Dinesh Neupane
    • - Dr Omkar Dhungel

    • Lucky draw winners:
    • - Dr Niru Yadav
    • - Dr Manisha Shah
    • - Dr Prakash Khadka
    • - Dr Bikash Jha
    • - Dr Sajita Paudel

    Winners are requested to send an email to onlinepgnepal@gmail.com to cliam Free Access to Today evening CEE MD/MS Based Online Model Test [07:00 PM, Kartik 5, 2077, Wednesday].
  74. 74
    Answers and Winners of QUIZ for Mandatory CPD Topics Based Model test of Kartik 12 (Wednesday, 07:00 PM).

    • 1. Cough CPR means:
    • a. Cough may be produced during CPR in unconscious patient
    • b. Cough can act as CPR in conscious patient with severe arrhythmia
    • c. Cough in unconscious patient may be an indicator of need of CPR
    • d. Cough is poor prognostic indicator during CPR

    • Ans: b
    • Repeated, forceful coughing (Cough CPR) can sustain consciousness during hypotensive events including VF for as long as 100 seconds when the arrhythmia (or any arrhythmia capable of rapidly compromising cardiac output) is immediately recognized and the patient can be verbally prompted to cough.

    • 2. Which of the following is not social influencing skill?
    • a. Feedback
    • b. Punishment
    • c. Challenge/directive
    • d. Self-disclosure

    • Ans: b
    • Social influencing skills help clients to explore more deeply their concerns and encourage them to make changes in their attitudes and behaviors. Some of the most important social influencing skills are:
    • - Interpretation/reframing: provide client with a new way to view or understand the situation
    • - Challenge/directive: support clients but pointing out discrepancies or mixed messages in their thoughts or behavior and suggesting alternative ways of thinking and behaving
    • - Self-disclosure: clinicians share selective personal experiences with the client when appropriate
    • - Feedback: provides clients with information on how others might perceive their thoughts or behavior
    • - Influencing summary: clarifies what has been discussed so client will be encouraged to think or act in different ways between sessions

    • 3. Doctor is ethically and legally bound to maintain confidentiality between physician and patient except:
    • a. When wife wants to know about husband
    • b. Father wants to know about son
    • c. Patient is harm to others or self
    • d. All of the above

    • Ans: c
    • Confidentiality between physician and patient is generally absolute
    • Exceptions
    • • Suspicion of child/elder abuse
    • • Gunshot or stabbing injuries must be reported to the police
    • • Communicable disease must be reported
    • • Patient is a harm to others or self: Tarasoff decision
    • • No alternative means exists to warn others
    • • Patient waves right to privacy e.g., for insurance purposes

    • 4. Which of the following is a useful marker of resuscitation?
    • a. Hydrate
    • b. Lactate
    • c. Bicarbonate
    • d. Phosphate

    • Ans: b
    • Measurement of blood lactate is recommended to stratify patients based on the need for ongoing fluid resuscitation, the risk of multiple organ dysfunction syndrome and death, as a marker for identifying patients requiring early aggressive resuscitation.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Keshav Adhikari
    • - Dr Sushila Gyawali

    • Lucky draw winners:
    • - Dr Anamol Adhikari
    • - Dr Roshani Napit

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free access to Mandatory CPD Based Model test of Kartik 12 (Wednesday, 07:00 PM).
  75. 75
    Answers & Winners of QUIZ for Today's CEE MD/MS Based Online Model Test [11:00 AM, Kartik 15, 2077, Saturday].

    • 1. Which ligament prevents the posterior translation of tibia on femur?
    • a. Anterior cruciate ligament
    • b. Posterior cruciate ligament
    • c. Medial collateral ligament
    • d. Lateral collateral ligament

    • Ans: b
    • Ref: Maheshwari Orthopedics, 5th edition, page 145
    •  Medial collateral: Prevents medial opening up
    •  Lateral collateral: Prevents lateral opening up
    •  Anterior cruciate: Prevents anterior translation of the tibia on the femur
    •  Posterior cruciate: Prevents posterior translation of the tibia on the femur

    • 2. A person presented with paroxysmal headache, palpitations and sweating attacks. He also has elevated blood pressure. On imaging it was found to be an adrenal tumor of size 3 cm and without any metastases. Which of the following is the most common approach regarding management?
    • a. Medical management
    • b. Wait and watch
    • c. Preoperative alpha blockers and open surgery
    • d. Preoperative alpha blockers and laparoscopic resection

    • Ans: d
    • Ref: Bailey and Love’s Short Practice of Surgery 27th Edition, Page No: 846
    • The given features suggest diagnosis of pheochromocytoma
    • • Laparoscopic resection is now routine in the treatment of pheochromocytoma. If the tumour is larger than 8–10 cm or radiological signs of malignancy are detected, an open approach should be considered
    • • Once a pheochromocytoma has been diagnosed, an α-adrenoreceptor blocker (phenoxybenzamine) is used to block the effects of catecholamine excess and its consequences during surgery.

    • 3. A child presented with the features of failure to thrive with foul smelling stool, ataxia. Peripheral blood smear showed acanthocytes. It was later diagnosed as a disorder of lipoprotein metabolism. Peripheral neuropathy developing in this condition is most likely due to:
    • a. Myelin deficiency
    • b. Vitamin B12 deficiency
    • c. Vitamin E deficiency
    • d. Pyridoxine deficiency

    • Ans: c
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1840
    • Abetalipoproteinemia
    • Abetalipoproteinemia is a rare autosomal recessive disorder of lipoprotein metabolism (Bassen­Kornzweig syndrome). It is associated with severe fat malabsorption from birth. Children fail to thrive during the 1st yr of life, with stools that are pale, foul smelling, and bulky. The abdomen is distended and deep tendon reflexes are absent as a result of peripheral neuropathy, which is secondary to vitamin E (fat­soluble vitamin) deficiency. Intellectual development tends to be slow. After 10 yr of age, intestinal symptoms are less severe, ataxia develops, and there is a loss of position and vibration sensation with the onset of intention tremors unless vitamin E levels are maintained in the normal range.

    • 4. Mechanism of action of Oseltamivir as an antiviral agent is
    • a. Inhibition of M2 receptor
    • b. Neuraminidase inhibition
    • c. Inhibition of RNA dependent DNA Polymerase
    • d. Apoptosis of infected cells

    • Ans: b
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 7th Edition, Page No: 802
    • Oseltamivir
    • This newer anti-influenza virus drug is a sialic acid analogue with broad spectrum activity covering influenza A, H5N1 (bird flu), H1N1 (swine flu) strains and influenza B. It is an ester prodrug that is rapidly and nearly completely hydrolysed during absorption in intestine and by liver to the active form oseltamivir carboxylate with an oral bioavailability of ~ 80%. The active metabolite is not further metabolized and is excreted by the kidney with a t½ of 6–10 hours. It acts by inhibiting influenza virus neuraminidase enzyme which is needed for release of progeny virions from the infected cell.
    • Anti-Influenza virus: Amantadine, Rimantadine, Oseltamivir, Zanamivir

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Dinesh Neupane
    • - Dr Aman Neupane

    • Lucky draw winners:
    • - Dr Jharana Rawat
    • - Dr Saroj Khanal

    Winners are requested to send an email to onlinepgnepal@gmail.com to get Free access to Today's CEE MD/MS Based Online Model Test [11:00 AM, Kartik 15, 2077, Saturday].
  76. 76
    • Gynecology/Obstetric QUIZ
    • Answers & Winners of QUIZ for Subjectwise (Gynae/Obs, ENT, Ortho) Based Online Model Test [07:00 PM, Kartik 17, 2077, Monday].

    • 1. A pelvis characterized by an anteroposterior diameter of the inlet greater than the transverse diameter is classified as:
    • a. Gynecoid
    • b. Android
    • c. Anthropoid
    • d. Platypelloid

    • Ans: c
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 403
    • • Normal female pelvis – Gynaecoid pelvis.
    • • Male type pelvis – Android pelvis.
    • • Most common type of pelvis – Gynaecoid pelvis.
    • • Least common type pelvis – Platypelloid pelvis.
    • • The only pelvis with AP diameter more than transverse diameter – Anthropoid pelvis.
    • • Face to pubes delivery is most common in Anthropoid pelvis.
    • • Direct occipitoposterior position is most common in Anthropoid pelvis.
    • • Persistent occipitoposterior position is most common in Android pelvis.
    • • Deep transverse arrest/ Nonrotation/dystocia is most common in Android pelvis.
    • • Broad flat pelvis – Platypelloid pelvis.
    • • Transverse diameter is much more than AP diameter – Platypelloid pelvis.
    • • Engagement by exaggerated posterior asynclitism occurs in Platypelloid pelvis.
    • • Super subparietal instead of biparietal diameter engages in Platypelloid pelvis.

    • 2. Probability of achieving live birth within a single menstrual cycle is termed as:
    • a. Fertility
    • b. Fecundity
    • c. Fecundability
    • d. Potency

    • Ans: b
    • Ref: DC Dutta Textbook of Gynecology including Contraception; 6th Edition, Page No: 227
    • • Fecundity is the probability of achieving a live birth within a single cycle.
    • • Fecundability is defined as the probability of achieving a pregnancy within one menstrual cycle. In a healthy young couple, it is 20 percent.
    • • Fertility is simply the ability to produce offspring.
    • • Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.
    • • Potency is the ability to perform sexual intercourse

    • 3. A lady presented with complaints of excessive menstrual blood loss. What amount has to be lost in the cycle to be called it as menorrhagia?
    • a. > 50 ml
    • b. > 80 ml
    • c. > 100 ml
    • d. > 120 ml

    • Ans: b
    • Ref: DC Dutta Textbook of Gynecology including Contraception; 6th Edition, Page No: 185 – 186
    • Menorrhagia is defined as cyclic bleeding at normal intervals; the bleeding is either excessive in amount (> 80 mL) or duration (>7 days) or both.

    • 4. A pregnant lady without any previous ANC visits presented near term without remembering her exact LMP. During examination, there was spontaneous rupture of membrane and the liquor was found to be saffron colored. The likely cause is:
    • a. Fetal distress
    • b. Hemorrhage
    • c. Post maturity
    • d. Rh incompatibility

    • Ans: c
    • Ref: DC Dutta Textbook of Obstetrics including Perinatology and Contraception 8th Edition, Page No: 43
    • In early pregnancy the amniotic fluid is colorless, but near term it becomes pale straw colored due to the presence of exfoliated lanugo and epidermal cells from the fetal skin. It may look turbid due to the presence of vernix caseosa.
    • Abnormal color: Deviation of the normal color of the liquor has got clinical significance.
    • • Meconium stained (green) is suggestive of fetal distress in presentations other than the breech or transverse. Depending upon the degree and duration of the distress, it may be thin or thick or pea soup (thick with flakes). Thick with presence of flakes suggests chronic fetal distress.
    • • Golden color in Rh incompatibility is due to excessive hemolysis of the fetal RBC and production of excess bilirubin.
    • • Greenish yellow (saffron) in post maturity.
    • • Dark colored in concealed accidental hemorrhage is due to contamination of blood.
    • • Dark brown (tobacco juice) amniotic fluid is found in IUD. The dark color is due to frequent presence of old HbA.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Subash Lamichhane
    • - Dr Sareen Shrestha

    • Lucky draw winners:
    • - Dr Aastha Ghimire
    • - Dr Sagar Koirala

    Winners are requested to claim send email to onlinepgnepal@gmail.com to claim Free Access to Subjectwise (Gynae/Obs, ENT, Ortho) Based Online Model Test [07:00 PM, Kartik 17, 2077, Monday].
  77. 77
    • Orthopedics QUIZ
    • Answers & Winners of QUIZ for Subjectwise (Gynae/Obs, ENT, Ortho) Based Online Model Test [07:00 PM, Kartik 17, 2077, Monday].

    • 1. What is March fracture?
    • a. Fracture of 2nd metatarsal
    • b. Fracture of 4th metatarsal
    • c. Fracture of cuboids
    • d. Fracture of tibia

    • Ans: a
    • Ref: Maheshwari Orthopedics 5th Edition Page No: 3
    • • Chance fracture: Also called seat belt fracture, the fracture line runs horizontally through the body of the vertebra, through and through, to the posterior elements.
    • • March fracture: Fatigue fracture of the shaft of 2nd or 3rd metatarsal.
    • • Burst fracture: It is a comminuted fracture of the vertebral body where fragments ‘‘burst out’’ in different directions.
    • • Clay-Shoveller fracture: It is an avulsion fracture of spinous process of one or more of the lower cervical or upper thoracic vertebrae.

    • 2. Three bony point relationship is maintained in:
    • a. Supracondylar Fracture humerus
    • b. Dislocation of elbow
    • c. Fracture Lateral condyle
    • d. Intercondylar Fracture

    • Ans: a
    • Ref: Maheshwari Orthopedics 5th Edition Page No: 98
    • On examination of supracondylar fracture:
    • • When presented early, before significant swelling has occurred, the following clinical signs may be observed:
    • o Unusual posterior prominence of the point of the elbow (tip of olecranon) because of the backward tilt of the distal fragment.
    • o Since the fracture is above the condyles, the three bony points relationship is maintained as in a normal elbow

    • 3. Charlie Chaplin gait is seen in?
    • a. Congenital coxa vara
    • b. Tibial torsion
    • c. Genu valgus
    • d. CDH

    • Ans: b
    • Ref: Maheshwori Orthopedics, 5th Edition, Page No: 370
    • GAITS
    • • Antalgic gait: occurs in painful condition of lower limb
    • • Charlie Chaplin gait: occurs in tibial torsion
    • • Circumduction gait: occurs in hemiplegia
    • • Duck waddling gait: occurs in bilateral CDH
    • • High stepping gait: occurs in foot drop
    • • Sailor’s gait: occurs in bilateral CDH
    • • Scissoring gait: occurs in CP
    • • Stiff hip gait: occurs in ankylosis of the hip
    • • Trendelenburg gait: occurs in an unstable hip due to CDH, gluteus medius weakness etc.

    • 4. A 26-year-old national swimmer underwent a left medial meniscal allograft transplantation. She returns after 3 years with knee pain. What is the most likely cause for late presenting knee pain in this patient population?
    • a. Late immune rejection of the meniscal graft
    • b. Loss of graft fixation
    • c. Osteoarthritis
    • d. Graft tear due to acellularity

    • Ans: d
    • The most common long-term complication after meniscal transplantation is meniscal graft tear. Graft failure that results from graft tears is thought to be related to the acellularity of graft tissue.
    • Meniscal allograft transplantation is considered a salvage treatment option for young patients (<50 years old) with symptomatic meniscal deficiencies. The overall complication rate ranges from 4-36%, which include meniscal tearing, acute immune rejection, superficial and deep infection, chronic knee pain, etc. Graft tears make up >50% of these complications.

    • Winners:
    • Fastest correct answer respondnets:
    • - Dr Diwas Sunar
    • - Dr Bibek Chhetri

    • Lucky draw winners:
    • - Dr Dhiraj Thakur
    • - Dr GR Khatri

    Winners are requested to claim send email to onlinepgnepal@gmail.com to claim Free Access to Subjectwise (Gynae/Obs, ENT, Ortho) Based Online Model Test [07:00 PM, Kartik 17, 2077, Monday].
  78. 78
    Answers and Winners of QUIZ for Today evening CEE Based Model test of Kartik 19 (Wednesday, 07:00 PM).

    • 1. Night cries is a clinical features of:
    • a. Osteomyelitis
    • b. Brucellosis
    • c. Tuberculosis
    • d. Septic arthritis

    • Ans: c
    • Ref: Ebnezar Orthopedics 4th Edition, Page No: 565
    •  Tuberculosis of hip is common in the first three decades of life.
    •  The patient usually presents with painful limp and is the most common earliest symptom. He or she has an antalgic gait with a short stance phase.
    •  Pain is maximum towards the end of the day and there is a history of night cries. There is marked wasting of the thigh and gluteal muscles. There may be presence of scars and sinuses.

    • 2. An individual who has all of the signs and symptoms of a disease or condition, yet has not been diagnosed is:
    • a. Primary case
    • b. Index case
    • c. Secondary case
    • d. Suspect case

    • Ans: d
    • Ref: Park's Textbook of Preventive and Social Medicine; 24th Edition; Page No: 100
    •  In epidemiological terminology, the term primary case refers to the first case of a communicable disease introduced into the population unit being studied.
    •  The term index case refers to the first case to come to the attention of the investigator; it is not always the primary case.
    •  Secondary cases are those developing from contact with primary case.
    •  A suspect case is an individual (or a group of individuals) who has all of the signs and symptoms of a disease or condition, yet has not been diagnosed as having the disease or had the cause of the symptoms connected to the suspected pathogen.

    • 3. Which variant of AML is associated with Auer rods?
    • a. Acute myeloblastic leukemia
    • b. Acute promyelocytic leukemia
    • c. Acute myelomonocytic leukemia
    • d. Acute monocytic leukemia

    • Ans: b
    • Ref: Robbins Basic Pathology, 10th edition, page 479
    • • Auer rods, distinctive red-staining rodlike structures, may be present in myeloblasts or more differentiated cells; they are particularly numerous in acute promyelocytic leukemia.
    • • Auer rods are specific for neoplastic myeloblasts and thus are a helpful diagnostic clue when present.
    • • In other subtypes of Acute Myeloid Leukemia, monoblasts, erythroblasts, or megakaryoblasts predominate.

    • 4. Which is not a rifled weapon?
    • a. Automatic pistol
    • b. Machine gun
    • c. Revolver
    • d. Shot gun

    • Ans: d
    • Ref: Gautam Biswas Forensic, 3rd edition, page 210
    • Firearms are broadly classified into two categories depending on the type of barrel:
    • i. Rifled weapons
    • o Rifles: 0.22, single shot, lever action, bolt-action, pump action, auto-loading
    • o Revolvers: Swing-out, break-top, solid-frame
    • o Single shot pistols
    • o Auto-loading pistols
    • o Submachine guns
    • o Machine guns
    • ii. Smooth bore weapons (shotguns)
    • o Single-shot
    • o Bolt action
    • o Double barrel
    • o Pump-action
    • o Lever action
    • o Auto-loading

    • Winners:
    • - Dr Prayas Poudel
    • - Dr Preeti Basnet

    • Lucky draw winners:
    • - Dr Suman Maharjan
    • - Dr Sachita Chapagain

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening CEE Based Model test of Kartik 19 (Wednesday, 07:00 PM).
  79. 79
    Answers and Winners of QUIZ for CEE MD/MS Based Online Model Test [11:00 AM, Kartik 22, 2077, Saturday].

    • 1. Maternal antibodies are present in the newborn against all of the following disease except:
    • a. Diphtheria
    • b. Tetanus
    • c. Pertussis
    • d. Measles

    • Ans: c
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 163
    • Infants are susceptible to infection from birth because maternal antibody does not appear to give them protection. There is no cross immunity with B. parapertussis.

    • 2. Which nerve is commonly harvested to be used as graft?
    • a. Dorsal cutaneous nerve
    • b. Peroneal nerve
    • c. Sural nerve
    • d. Tibial nerve

    • Ans: c
    • Ref: Apley and Soloman’s Orthopaedics, 10th edition, page 285 – 286
    • • Free autogenous nerve grafts can be used to bridge gaps too large for direct suture. The sural nerve is most commonly used; up to 40 cm can be obtained from each leg.
    • • Because the nerve diameter is small, several strips may be used (cable graft). The graft should be long enough to lie without any tension, and it should be routed through a well-vascularized bed.
    • • The graft is attached at each end either by fine sutures or with fibrin glue. It is crucial that the motor and sensory fascicles are appropriately connected by the graft.

    • 3. Intraosseous line is usually kept in:
    • a. Humerus
    • b. Tibia
    • c. Sternum
    • d. Radius

    • Ans: b
    • Volume resuscitation
    • • Vascular access and monitoring are essential for proper volume resuscitation.
    • • Establish IV access early with awareness that the rate at which crystalloid can be infused is dependent on the catheter diameter and the driving pressure. Large bore peripheral IVs may be as adequate for volume resuscitation as central lines.
    • • Maintaining vascular access above the diaphragm is important if concern exists regarding vascular injury in the abdomen or pelvis.
    • • For adults and especially children, an intraosseous (IO) line may be placed in the distal femur or proximal tibia within 90 seconds for a truly unstable patient with inadequate peripheral access.
    • • Initial fluid resuscitation is generally accepted to begin with the infusion of crystalloids. If no acceptable hemodynamic improvement occurs after 2-3 L infusion of crystalloids in patients with shock, a blood transfusion may be needed.
    • • In the setting of massive hemorrhage, beginning blood transfusion immediately is appropriate.
    • • For children, an initial fluid bolus of 20 mL/kg of crystalloids over 0-20 minutes may be repeated twice, followed by a transfusion of 10 mL/kg warm pack red blood cells (PRBCs) if the patient remains unstable.

    • 4. Juvenile polyposis is associated with the mutation in:
    • a. APC
    • b. TP 53
    • c. STK 11
    • d. SMAD 4

    • Ans: d
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 599
    • • Cowden syndrome: PTEN
    • • Juvenile polyposis: SMAD 4
    • • Li Fraumeni: TP53
    • • Gorlin’s syndrome: PTCH
    • • Peutz-Jeghers syndrome: STK 11(LKB1)

    • Winners:
    • Fastest Corret Answer respondents:
    • - Dr Diwas Sunar
    • - Dr Madhav Banjade

    • Lucky draw winners:
    • - Dr Sony Gupta
    • - Dr Rehan Pradhan

    Winners are requested to send an email to onlinepgnepal@gmail.com to cliam Free Access to CEE MD/MS Based Online Model Test [11:00 AM, Kartik 22, 2077, Saturday].
  80. 80
    Answers and Winners of QUIZ for USMLE Step 1 First Aid Based Online Model Test [07:00 PM, Kartik 24, 2077, Monday].

    • 1. Which of the following prevent strands from reannealing?
    • a. Single-stranded binding proteins
    • b. Helicase
    • c. DNA ligase
    • d. Primase

    • Ans: a
    • Ref: USMLE Step 1 First Aid 2020, Page No: 38
    • • Single-stranded binding proteins: Prevent strands from reannealing.
    • • Helicase: Unwinds DNA template at replication fork.
    • • DNA ligase: Catalyzes the formation of a phosphodiester bond within a strand of double-stranded DNA.
    • • Primase: Makes an RNA primer on which DNA polymerase III can initiate replication.

    • 2. Methylmalonic acidemia is seen in deficiency of:
    • a. Folate
    • b. Vitamin B12
    • c. Ascorbic acid
    • d. Vitamin K

    • Ans: b
    • Ref: USMLE Step 1 First Aid 2020, Page No: 85
    • Methylmalonic acidemia: Deficiency of methylmalonyl-CoA mutase or vitamin B12.

    • 3. Primary immune organ is:
    • a. Thymus
    • b. Lymph node
    • c. Spleen
    • d. Tonsil

    • Ans: a
    • Ref: USMLE Step 1 First Aid 2020, Page No: 96
    • Immune system organs
    • 1° organs:
    • • Bone marrow—immune cell production, B cell maturation
    • • Thymus—T cell maturation
    • 2° organs:
    • • Spleen, lymph nodes, tonsils, Peyer patches
    • • Allow immune cells to interact with antigen

    • 4. Pulmonary capillary wedge pressure is a good approximation of:
    • a. Left atrial pressure
    • b. Right atrial pressure
    • c. Left ventricular pressure
    • d. Right ventricular pressure

    • Ans: a
    • Ref: USMLE Step 1 First Aid 2020, Page No: 297
    • Pulmonary capillary wedge pressure (PCWP; in mm Hg) is a good approximation of left atrial pressure. In mitral stenosis, PCWP > LV end diastolic pressure. PCWP is measured with pulmonary artery catheter (Swan-Ganz catheter).

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Kiran Bhandari
    • - Dr Diwas Sunar

    • Lucky draw winners
    • - Dr Anuj Baruwal
    • - Dr Sheetal Shrestha

    Winners are requested to send an email to onlinepgnepal@gmail.com to cliam Free Acess to USMLE Step 1 First Aid Based Online Model Test [07:00 PM, Kartik 24, 2077, Monday].
  81. 81
    Answers and Winners of QUIZ for CEE MD/MS Based Online Model Test [07:00 PM, Kartik 26, 2077, Wednesday].

    • 1. Most common chromosomal disorder causing mental retardation
    • a. Down's syndrome
    • b. Hypothyroidism
    • c. Klinefelter syndrome
    • d. Fragile X syndrome

    • Ans: a
    • Ref: Robbins Basic Pathology 9th Edition, Page No: 161
    • Trisomy 21 (Down Syndrome)
    • • Down syndrome is the most common of the chromosomal disorders and is a major cause of mental retardation.
    • • In the United States the incidence in newborns is about 1 in 700.
    • • Approximately 95% of affected individuals have trisomy 21, so their chromosome count is 47.
    • • FISH with chromosome 21–specific probes reveals the extra copy of chromosome 21 in such cases.
    • • Maternal age has a strong influence on the incidence of trisomy 21.

    • 2. Which of the following changes is not seen in congenital dislocation of the hip?
    • a. Acetabulum is shallow
    • b. Adaptive shortening adductor group of muscles
    • c. Femoral head dislocated upwards and laterally
    • d. Femoral neck retroverted

    • Ans: d
    • Ref: Maheshwari Orthopedics, 5th edition, page 220
    • Following changes are seen in a congenitally dislocated hip joint:
    • • Femoral head is dislocated upwards and laterally; its epiphysis is small and ossifies late.
    • • Femoral neck is excessively anteverted.
    • • Acetabulum is shallow, with a steep sloping roof.
    • • Ligamentum teres is hypertrophied.
    • • Fibro-cartilaginous labrum of the acetabulum (limbus) may be folded into the cavity of the acetabulum (inverted limbus).
    • • Capsule of the hip joint is stretched.
    • • Muscles around the hip, especially the adductors, undergo adaptive shortening.

    • 3. How many hours after death does "tache noir" occur?
    • a. Immediately after death
    • b. Within 30 minutes
    • c. Within 2 hours
    • d. Within 3 to 4 hours

    • Ans: d
    • Ref: Reddy Forensic Medicine, 33rdedition, page 153
    • Opacity of the Cornea:
    • • This may occur in certain diseases (cholera, wasting diseases) before death.
    • • The opacity is due to drying and is delayed for about two hours if the lids are closed after death. If the eyelids are open for a few hours after death, a film of cell debris and mucus forms two yellow triangles on the sclera at each side of the iris, with base towards the margin of cornea and apex towards medial or lateral canthus of the eye, which become brown and then black called "tache noir" within 3 to 4 hours, upon which dust settles and the surface becomes wrinkled (artefact).

    • 4. Which of the following reflects the diagnostic power of the test?
    • a. False-positivity
    • b. Predictive value
    • c. Sensitivity
    • d. Yield

    • Ans: b
    • Ref: Park’s PSM, 23rd edition, page 140
    • o In addition to sensitivity and specificity, the performance of a screening test is measured by its "predictive value" which reflects the diagnostic power of the test.
    • o The predictive accuracy depends upon sensitivity, specificity and disease prevalence. The "predictive value of a positive test" indicates the probability that a patient with a positive test result has, in fact, the disease in question.
    • o The more prevalent a disease is in a given population, the more accurate will be the predictive value of a positive screening test. The predictive value of a positive result falls as disease prevalence declines.

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Subash Lamichhane
    • - Dr Dinesh Neupane

    • Lucky dra winners:
    • - Dr Acharya B Raj
    • - Dr Prashamsha Tamrakar

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to CEE MD/MS Based Online Model Test [07:00 PM, Kartik 26, 2077, Wednesday].
  82. 82
    Answers and Winners of QUIZ for Today evening CEE MD/MS Based Online Model Test [07:00 PM, Mangsir 3, 2077, Wednesday].

    • 1. Most common complication of Mumps in children is:
    • a. Orchitis
    • b. Aseptic meningitis
    • c. Myocarditis
    • d. Arthritis

    • Ans: b
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1552-1553
    • Mumps is an acute self-limited infection that was once common place but is now unusual in developed countries because of widespread use of vaccination. It is characterized by fever, bilateral or unilateral parotid swelling and tenderness, and the frequent occurrence of meningoencephalitis and orchitis. Although no longer common in countries with extensive vaccination programs, mumps remains endemic in the rest of the world, warranting continued vaccine protection.
    • • The most common complications of mumps are meningitis, with or without encephalitis, and gonadal involvement. Uncommon complications include conjunctivitis, optic neuritis, pneumonia, nephritis, pancreatitis, and thrombocytopenia.
    • • Maternal infection with mumps during the 1st trimester of pregnancy results in increased fetal wastage. No fetal malformations have been associated with intrauterine mumps infection. However, perinatal mumps disease has been reported in infants born to mothers who acquired mumps late in gestation.

    • 2. Antidote for Methotrexate toxicity:
    • a. Folic acid
    • b. Folinic acid
    • c. Thymine
    • d. Vitamin B

    • Ans: b
    • Ref: KD Tripathi Essentials of Medical Pharmacology; 7th Edition, Page No: 611
    • Methotrexate toxicity
    • • Folinic acid (Leucovorin, citrovorum factor, 5-formyl-THFA) is an active coenzyme form which does not need to be reduced by DHFRase before it can act. Methotrexate is a DHFRase inhibitor; its toxicity is not counteracted by folic acid, but antagonized by folinic acid (3.0 mg i.v. repeated as required).

    • 3. Not transmitted by mite:
    • a. Scabies
    • b. Scrub typhus
    • c. KFD
    • d. Rickettsial pox

    • Ans: c
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 768
    • Trombiculid mite
    •  Scrub typhus
    •  Rickettsial pox
    • Itch mite
    •  Scabies
    • Hard tick
    •  Tick typhus
    •  Viral encephalitis
    •  Viral fevers
    •  Viral hemorrhagic fever
    •  Kyasanur forest disease
    •  Tularemia
    •  Tick paralysis
    •  Human babesiosis
    • Soft tick
    •  Q fever
    •  Relapsing Fever

    • 4. All of the following are features of Treacher Collins syndrome except
    • a. Mongoloid eyelids
    • b. Aural atresia
    • c. Hypoplasia of mandible
    • d. Lower lid coloboma

    • Ans: a
    • Ref: PL Dhingra and Shruti Dhingra ENT and HNS 6th Edition, Page No: 116
    • Treacher-Collins syndrome (mandibulofacial dysostosis):
    •  Antimongoloid palpebral fissures
    •  Coloboma of lower lid
    •  Hypoplasia of mandible and malar bones
    •  Microtia pinna and meatal atresia
    •  Malformed malleus and incus (stapes normal)

    • Winners:
    • Fastest correct answer respondents:
    • - Dr Subash Lamichhane
    • - Dr Sushil Parajuli

    • Lucky draw winners:
    • - Dr Bikash Jha
    • - Dr Esha Shrestha

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening CEE MD/MS Based Online Model Test [07:00 PM, Mangsir 3, 2077, Wednesday].
  83. 83
    Answers and Winners of QUIZ for Combined Past Question Based Online Model Test [07:00 PM, Mangsir 8, 2077, Monday].

    • 1. The nerve from which the parasympathetic fibers for the parotid gland take origin is: [IOM 2010]
    • a. Vagus
    • b. Facial
    • c. Glossopharyngeal
    • d. Trigeminal

    • Ans: c
    • Ref: USMLE Step 1 First Aid 2020, Page No: 506
    • Glossopharyngeal nerve function:
    • Taste and sensation from posterior 1/3 of tongue, swallowing, salivation (parotid gland), monitoring carotid body and sinus chemo- and baroreceptors, and elevation of pharynx/larynx (stylopharyngeus)

    • 2. Which of the following is not seen in cerebral malaria? [KU 2019]
    • a. ARDS
    • b. Hyperglycemia
    • c. Abortion
    • d. Hypotension

    • Ans: b
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1373
    • Cerebral Malaria
    • • Coma is a characteristic and ominous feature of falciparum malaria and, despite treatment, is associated with death rates of ~20% among adults and 15% among children.
    • • Any obtundation, delirium, or abnormal behavior should be taken very seriously.
    • • The onset may be gradual or sudden following a convulsion.
    • Hypoglycemia, an important and common complication of severe malaria, is associated with a poor prognosis and is particularly problematic in children and pregnant women.
    • Lab features of severe malaria:
    • • Hypoglycemia (<2.2 mmol/L)
    • • Hyperlactatemia (>5 mmol/L)
    • • Acidosis (arterial pH <7.3, serum HCO3 <15 mmol/L)
    • • Elevated serum creatinine (>265 μmol/L)
    • • Elevated total bilirubin (>50 μmol/L)
    • • Elevated liver enzymes (AST/ALT 3 times upper limit of normal)
    • • Elevated muscle enzymes (CPK ↑, myoglobin ↑)
    • • Elevated urate (>600 μmol/L)

    • 3. Screening test specificity is the ability of a test to correctly identify: [BPKIHS 2017]
    • a. False positives
    • b. True positives
    • c. True negatives
    • d. False negatives

    • Ans: c
    • Ref: USMLE Step 1 First Aid 2020, Page No: 257
    • Specificity (true negative rate)
    • • Proportion of all people without disease who test negative, or the probability that when the disease is absent, the test is negative.
    • • Value approaching 100% is desirable for ruling in disease and indicates a low false-positive rate.

    • 4. Thumbs up position is done by which nerve? [Pokhara 2nd set]
    • a. Median nerve
    • b. Anterior interosseous nerve
    • c. Posterior interosseous nerve
    • d. Ulnar

    • Ans: c
    • Thumbs Up: PIN (Radial Nerve)
    • OK Sign: AIN (Median Nerve)
    • Spread Fingers: Ulnar Nerve

    • Winners:
    • Dr Sujata Chaudhary
    • Dr Subasha Lamichhane
    • Dr Astha Ghimire
    • Dr Sulav Shrestha

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening Combined Past Question Based Online Model Test [07:00 PM, Mangsir 8, 2077, Monday].
  84. 84
    • Renal angle lies:
    • a. Between external oblique and pubic tubercle
    • b. Erector spinalis and 12th thoracic vertebrae
    • c. Erector spinalis and 11th thoracic vertebrae
    • d. External oblique and anterior iliac line.

    • Ans: b
    • Ref: BDC Human Anatomy, 6th Edition, Volume II, Page No: 197
    • The angle between the last rib and outer border of erector spinae is known as renal angle. It overlies the lower part of kidney. The twelfth rib may only be just palpable lateral to erector spinae or may extend for some distance beyond it.



    • In a patient of jaundice, absence of urobilinogen in urine indicates?
    • a. Obstructive jaundice
    • b. Hemolysis
    • c. Liver failure
    • d. Hepatitis

    • Ans: a
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 280
    • o The conjugated bilirubin excreted into bile drains into the duodenum and passes unchanged through the proximal small bowel.
    • o Conjugated bilirubin is not taken up by the intestinal mucosa.
    • o It is hydrolyzed to unconjugated bilirubin by bacterial glucuronidase.
    • o The unconjugated bilirubin is reduced by normal gut bacteria to form group of colorless tetrapyrrole called urobilinogen.

    • Inability to perform physical activity without discomfort falls under:
    • a. NYHA class 1
    • b. NYHA class 2
    • c. NYHA class 3
    • d. NYHA class 4

    • Ans: d
    • Ref: Davidson’s Medicine 23rd Edition, page No: 454
    • New York Heart Association (NYHA) functional classification:
    • • Class 1: No limitation during ordinary activity
    • • Class2: Slight limitation during ordinary activity
    • • Class 3: Marked limitation of normal activities without symptoms at rest
    • • Class 4: Unable to undertake physical activity without symptoms; symptoms may be present at rest

    • Shepherd Crook deformity is a feature of:
    • a. Fibrous dysplasia
    • b. Post polio paralysis
    • c. Cerebral palsy
    • d. Perthes disease

    • Ans: a
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 370
    • Classic features
    •  Aneurysmal sign: TB spine (anterior type)
    •  Fabella: sesamoid bone in the lateral head of gastrocnemius
    •  Onion-peel appearance: Ewing’s Sarcoma
    •  Patchy calcification: Chondrosarcoma
    •  Riser’s sign: Epiphysis of iliac bone
    •  Sagging rope sign: Perthes’ disease
    •  Shepherd Crook deformity: Fibrous dysplasia
    •  Soap-bubble appearance: Osteoclastoma
    •  Spondylolisthesis: slip of one vertebra over other
    •  Spondylolysis: break in posterior elements (at pars interarticularis)
    •  Spondylosis: degenerative spine disease
    •  Sun-ray appearance: Osteosarcoma
    •  Tonguing of vertebra: Morquio-Brails disease
    •  Trethowan’s sign: Slipped capital femoral epiphysis
    •  Wormian bones: Osteogenesis imperfecta

    • Most common acute complication of hemodialysis is?
    • a. Infection
    • b. Hypotension
    • c. Anemia
    • d. Anaphylactoid reactions

    • Ans: B
    • Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1824
    • • Hypotension is the most common acute complication of hemodialysis, particularly among patients with diabetes mellitus.
    • • Numerous factors appear to increase the risk of hypotension, including excessive ultrafiltration with inadequate compensatory vascular filling, impaired vasoactive or autonomic responses, osmolar shifts, overzealous use of antihypertensive agents, and reduced cardiac reserve.
  85. 85
    • Agnes hunt traction is used for:
    • a. Open forearm fracture
    • b. Scoliosis
    • c. Trochanteric traction
    • d. Correction of hip deformity

    • Ans: D
    • Ref: Essential Orthopedics by Maheshwari & Mhaskar, 5th Edition, Page No: 27
    • Traction systems and their uses
    • • Gallow's traction Fracture shaft of the femur in children below 2 years
    • • Bryant's traction Fracture shaft of the femur in children below 2 years
    • • Russell's traction Trochanteric fractures
    • • Buck's traction Conventional skin traction
    • • Perkin's traction Fracture shaft of femur in adults
    • • 90°-90° traction Fracture shaft of femur in children
    • • Agnes-Hunt traction Correction of hip deformity
    • • Well-leg traction Correction of adduction or abduction deformity of hip
    • • Dunlop traction Supracondylar fracture of humerus
    • • Smith's traction Supracondylar fracture of humerus
    • • Calcaneal traction Open fractures of ankle or leg
    • • Metacarpal traction Open forearm fractures
    • • Head-halter traction Cervical spine injuries
    • • Crutchfield traction Cervical spine injuries
    • • Halo-pelvic traction Scoliosis


    • Patient counselling should be done by:
    • a. Treating physician
    • b. Nursing staff who takes care
    • c. Health administrator
    • d. Junior doctor who attends round

    • Ans: a
    • Communication is the transfer of information meaningful to those involved. It is the process in which messages are generated and sent by one person and received and translated by another person. However, the meaning generated by the receiver can be different from the sender’s intended message.
    • The communication process between health professionals and patients serves two primary functions.
    •  It establishes an ongoing relationship between the professional and the patient.
    •  It provides the exchange of information necessary to assess a patient’s health condition, implement treatment of medical problems, and evaluate the effects of treatment on a patient’s quality of life.
    • The healthcare professional must be able to
    • - understand the illness experience of the patient
    • - perceive each patient’s experience as unique
    • - foster a more egalitarian relationship with patients
    • - build a therapeutic alliance with patients to meet mutually understood goals of therapy
    • - develop self-awareness of personal effects on patients

    • The healthcare professional should encourage patients to share experiences with therapy
    • because
    • - they have unanswered questions
    • - they have misunderstandings
    • - they experience problems to therapy
    • - they can “monitor” their own responses to treatment
    • - they make their own decisions regarding therapy
    • - they may not reveal information to you unless you initiate a dialogue
    • Communication during drug therapy
    • - Purpose of medication
    • - How medication works
    • - Dose and duration of therapy
    • - Goals of therapy
    • - How effectiveness will be monitored
    • - Adverse effects and how to deal with them
    • - Drug specific issues

    • MEN II is seen with which of the following thyroid carcinoma:
    • a. Follicular
    • b. Anaplastic
    • c. Medullary
    • d. Papillary

    • Ans: c
    • Ref: Sabiston Surgery 20th Edition, Page No: 1004
    • MEN IIa or SIPPLE'S SYNDROME consists of pheochromocytoma (tumors of adrenal medulla) with medullary carcinoma thyroid associated with adenoma or hyperplasia of parathyroid glands.
  86. 86
    Answers and Winners of QUIZ for Today evening Combined Past Question Based Online Model Test [07:00 PM, Mangsir 15, 2077, Monday].

    • 1. Which of the following is late manifestation of rheumatic fever?
    • a. Chorea
    • b. Arthritis
    • c. Carditis
    • d. Erythema marginatum

    • Ans: a
    • Ref: Nelson Textbook of Pediatrics, Elsevier, 20th Edition, Page No: 1334
    • Chorea
    • Sydenham chorea occurs in approximately 10-15% of patients with acute rheumatic fever and usually presents as an isolated, frequently subtle, movement disorder. Emotional lability, incoordination, poor school performance, uncontrollable movements, and facial grimacing, all exacerbated by stress and disappearing with sleep, are characteristic. Chorea occasionally is unilateral (hemichorea). The latent period from acute GAS infection to chorea is usually substantially longer than for arthritis or carditis and can be months. Onset can be insidious, with symptoms being present for several months before recognition.
    • Clinical maneuvers to elicit features of chorea include
    • • Demonstration of milkmaid’s grip (irregular contractions and relaxations of the muscles of the fingers while squeezing the examiner’s fingers),
    • • Spooning and pronation of the hands when the patient’s arms are extended,
    • • Wormian darting movements of the tongue upon protrusion, and
    • • Examination of handwriting to evaluate fine motor movements.
    • Diagnosis is based on clinical findings with supportive evidence of GAS antibodies. However, in the usual patient with a long latent period from the inciting streptococcal infection to onset of chorea, antibody levels have often declined to normal. Although the acute illness is distressing, chorea rarely, if ever, leads to permanent neurologic sequelae.

    • Erythema Marginatum
    • Erythema marginatum is a rare (approximately 1% of patients with acute rheumatic fever) but characteristic rash of acute rheumatic fever. It consists of erythematous, serpiginous, macular lesions with pale centers that are not pruritic. It occurs primarily on the trunk and extremities, but not on the face, and it can be accentuated by warming the skin.

    • 2. Large number of cases of acute hemorrhagic conjunctivitis occurring in different geographical area at period of time is called:
    • a. Endemic
    • b. Epidemic
    • c. Pandemic
    • d. Exotic

    • Ans: c
    • Ref: Park's Textbook of Preventive and Social Medicine; 23rd Edition; Page No: 93
    • Pandemic
    • An epidemic usually affecting a large proportion of the population, occurring over a wide geographic area such as a section of a nation, the entire nation, a continent or the world e.g., influenza pandemics of 1918 and 1957, cholera El Tor in 1962 (still continuing) and acute haemorrhagic conjunctivitis in 1971 and 1981.

    • Epidemic (Epi upon; demos = people)
    • • The "unusual" occurrence in a community or region of disease, specific health-related behaviour (e.g., smoking) or other health- related events (e.g., traffic accidents) clearly in excess of "expected occurrence".
    • • The amount of disease occurring in the past, in the absence of an epidemic, defines the "expected" frequency. Some use the term "outbreak" for a small, usually localized epidemic in the interest of minimizing public alarm, unless the number of cases is indeed very large
    • Endemic
    • • (En=in; demos=people). It refers to the constant presence of a disease or infectious agent within a given geographic area or population group, without importation from outside; may also refer to the "usual" or expected frequency of the disease within such area or population group.
    • • For instance, common cold is endemic because somebody always has one.

    • 3. The bronchopulmonary segment of a lung is not an independent because it is supplied by intersegmental
    • a. Bronchus
    • b. Pulmonary artery
    • c. Pulmonary vein
    • d. Bronchial artery

    • Ans: c
    • Ref: Moore's Clinically Oriented Anatomy; 7th Edition, Page No: 115
    • • Each main bronchus divides into secondary lobar bronchi, two on the left and three on the right, each of which supplies a lobe of the lung. Each lobar bronchus divides into several tertiary segmental bronchi that supply the bronchopulmonary segment. The bronchopulmonary segments are:
    • • Largest subdivision of a lobe
    • • Pyramidal shaped segments of the lung with their apices facing the lung root
    • • Separated from the adjacent segments by connective tissue septa
    • • Supplied independently by a segmental bronchus and a tertiary branch of a pulmonary artery
    • • Named according to the segmental bronchi supplying them
    • • Drained by intersegmental part of the pulmonary veins

    • 4. Triad of drug hypersensitivity is Rash, Fever and
    • a. Target lesions
    • b. Epidermal Detachment
    • c. Internal Organs involvement
    • d. Hematuria

    • Ans: c
    • Ref: Anticonvulsant hypersensitivity syndrome associated with carbamazepine administration: Case series by Maulin Mehta; J Pharmacol Pharmacother. 2014 Jan-Mar; 5(1): 59–62.
    • AHS is the triad of fever, rash, and internal organ involvement occurring 1-8 weeks after exposure to an anticonvulsant (1 in 1,000 to 10,000 exposures).

    • Winners:
    • - Dr Roshan Kumar Yadav
    • - Dr Rehan Pradhan
    • - Dr Ritu Shrestha
    • - Dr Sujita Khadka

    Winners are requested to send an email to onlinepgnepal@gmail.com to claim Free Access to Today evening Combined Past Question Based Online Model Test [07:00 PM, Mangsir 15, 2077, Monday].
  87. 87
    • Which anatomical finding best describes nutcracker syndrome?
    • a. Superior mesenteric artery compress transverse portion of duodenum.
    • b. Aorta compresses transverse portion of duodenum.
    • c. Superior mesenteric artery and aorta compress left renal vein between them.
    • d. Superior mesenteric artery and aorta compress right renal vein between them.

    • Ans: c
    • Ref: USMLE Step 1 First Aid 2020, Page No: 357
    • • Nutcracker syndrome is compression of left renal vein between superior mesenteric artery and aorta. It is characterized by flank pain and gross hematuria (d/t rupture of thin walled renal varicosities)
    • • Superior mesenteric artery syndrome is characterized by intermittent intestinal obstruction symptoms (primarily postprandial pain). It occurs when superior mesenteric artery and aorta compress the transverse (third) part of duodenum. It typically occurs in conditions associated with diminished mesenteric fat (eg, low body weight/malnutrition).

    • Pegloticase is useful in which condition?
    • a. Hypercalcemia
    • b. Hyperkalemia
    • c. Hypernatremia
    • d. Hyperuricemia

    • Ans: d
    • Ref: Katzung’s Basic & Clinical Pharmacology; Lange; 14th Edition, Page No: 663
    • • Pegloticase is the newest urate-lowering therapy to be approved for the treatment of refractory chronic gout.
    • • It is a recombinant mammalian uricase that is covalently attached to methoxy polyethylene glycol (mPEG) to prolong the circulating half-life and diminish immunogenic response.
    • • The recommended dose for pegloticase is 8 mg every 2 weeks administered as an intravenous infusion. It is a rapidly acting drug, achieving a peak decline in uric acid level within 24–72 hours. The serum halflife ranges from 6 to 14 days. Several studies have shown earlier clearance of PEG-uricase (mean of 11 days) due to antibody response when compared to PEG-uricase antibody-negative subjects (mean of 16.1 days).
    • • Urate oxidase enzyme, absent in humans and some higher primates, converts uric acid to allantoin. This product is highly soluble and can be easily eliminated by the kidney. Pegloticase has been shown to maintain low urate levels for up to 21 days after a single dose at doses of 4–12 mg, allowing for IV dosing every 2 weeks. Pegloticase should not be used for asymptomatic hyperuricemia.

    • Bimalleolar fracture is called:
    • a. Pott's fracture: Bimalleolar ankle fracture
    • b. Maissonaives fracture: spiral fracture of the upper third of the fibula associated with tear of the distal tibiofibular syndesmosis
    • c. Chopart’s fracture : Trimalleolar ankle fracture
    • d. Jone's fracture: extraarticular fracture at the base of 5th metatarsal
Author
Animesh
ID
352645
Card Set
Miscellaneous ll
Description
Updated