1. Here is the photograph of a child. This type of skin lesion are seen in which condition?

A. Neurofibromatosis
B. Sturge Weber syndrome
C. Tuberous sclerosis
D. Von hippel lindau disease
1. Ans. C. Tuberous sclerosis
1. Tuberous sclerosis (TS) is inherited as an autosomal dominant trait with variable penetrance and a prevalence of 1/6,000
people. Spontaneous genetic mutations occur in up to 75% cases. Molecular genetic studies have identified two foci for the
TS complex.
2. The TSC1 gene is located on chromosome 9q34, and the TSC2 gene is on chromosome 16p13. The 8.6-kb TSC1 transcript
encodes a protein of 130 kd called hamartin.
3. The TSC2 gene encodes the protein tuberin. Hamartin and tuberin act together as a single molecular complex at the Golgi
apparatus.
4. TS is an extremely heterogeneous disease with a wide clinical spectrum varying from severe mental retardation and
incapacitating seizures to normal intelligence and a lack of seizures, often within the same family.
5. As a rule, the younger the patient presents with symptoms and signs of TS, the greater is the likelihood of mental
retardation.
6. The disease affects many organ systems other than the skin and brain, including the heart, kidney, eyes, lungs, and bone.
2. What is your diagnosis after seeing this fundus?

A. Hypertensive retinopathy
C. Optic atrophy

B. Diabetes retinopathy
D. Retinitis pigmentosa

2. Ans. B. Diabetes retinopathy

1. Proliferative diabetic retinopathy with neovascularization of the disc.
2. The retinal changes of diabetes mellitus are classified as nonproliferative or proliferative. Nonproliferative diabetic
retinopathy is characterized by retinal microaneurysms, venous dilatation, retinal hemorrhages, and exudates.
3. The microaneurysms appear as tiny red dots. The hemorrhages may be of both the dot and blot type, representing deep
intraretinal bleeding, and the splinter or flame-shaped type, involving the superficial nerve fiber layer.
4. The exudates tend to be deep and to appear waxy. There may also be superficial nerve fiber infarcts called cytoid bodies or
cotton-wool spots, as well as retinal edema.
5. These signs may wax and wane. They are seen primarily in the posterior pole, around the disc and macula, well within the
range of direct ophthalmoscopy. Involvement of the macula may lead to decreased vision.
6. Proliferative retinopathy, the more serious form, is characterized by neovascularization and proliferation of fibrovascular
tissue on the retina, extending into the vitreous.

7.
8.
9.

Neovascularization may occur on the optic disc (NVD), elsewhere on the retina (NVE), or on the iris and in the anterior
chamber angle (NVI, or rubeosis irides).
Traction on these new vessels leads to hemorrhage and eventually scarring. The vision-threatening complications of
proliferative diabetic retinopathy are retinal and vitreous hemorrhages, cicatrization, traction, and retinal detachment.
Neovascularization of the iris may lead to secondary glaucoma if not treated promptly.

3. What is your diagnosis of a patient whose pure tone audiogram is given below?

A. Unilateral conductive hearing loss

B. Bilateral conductive hearing loss
C. Unilateral sensorineural hearing loss
D. Bilateral sensorineural hearing loss
3. Ans. B. Bilateral conductive hearing loss
Audiogram showing bilateral conductive hearing loss.
1. The technique of the audiologic evaluation varies as a function of the age or developmental level of the child, the reason for
the evaluation, and the child's otologic condition or history.
2. An audiogram provides the fundamental description of hearing sensitivity.
3. Hearing thresholds are assessed as a function of frequency using pure tones (sine waves) at octave intervals from 250
8,000 Hz. Earphones typically are used, and hearing is assessed independently for each ear.
4. Airconducted signals are presented through earphones (or loudspeakers) and are used to provide information about the
sensitivity of the auditory system.
5. These same test sounds can be delivered to the ear through an oscillator that is placed on the head, usually on the mastoid.
Such signals are considered bone-conducted because the bones of the skull transmit vibrations as sound energy directly to
the inner ear, essentially bypassing the outer and middle ears.
6. In a normal ear, and also in children with SNHL, the air and bone conduction thresholds are the same. In those with CHL, the
air and bone conduction thresholds differ.
7. This is called the airbone gap, which indicates the amount of hearing loss attributable to dysfunction in the outer and/or
middle ear. With mixed hearing loss, both the bone and air conduction thresholds are abnormal, and there is an airbone
gap.

4. What is your diagnosis of this child having Widespread skin lesion?

A. Scabies
C. Psoriasis

B. Seborrheic dermatitis
D. Lichen planus

4. Ans. B. Seborrheic dermatitis

SEBORRHEIC DERMATITIS.
1. This chronic inflammatory disease is most common in infancy and adolescence, paralleling the distribution, size, and activity
of the sebaceous glands. The cause is unknown, as is the role of the sebaceous glands in this disease.
2. It is also unknown whether infantile and adolescent seborrheic dermatitis are the same or different entities. There is no
evidence that children with infantile seborrheic dermatitis will develop seborrheic dermatitis as adolescents.
3. A generalized eruption with features of seborrheic dermatitis is common in HIV-infected children and adolescents.
Clinical Manifestations.
1. The disorder may begin in the 1st mo of life and may be most troublesome in the 1st yr. Diffuse or focal scaling and crusting
of the scalp, sometimes called cradle cap, may be the initial and at times the only manifestation.
2. A greasy, scaly, erythematous papular dermatitis, which is usually non-pruritic, may involve the face, neck, retroauricular
areas, axillae, and diaper area.
3. The dermatitis may be patchy and focal or may spread to involve almost the entire body. Postinflammatory pigmentary
changes are common, particularly in black infants.
4. When the scaling becomes pronounced, the condition may resemble psoriasis and, at times, can be distinguished only with
difficulty.
5. The possibility of coexistent atopic dermatitis must be considered when there is an acute weeping dermatitis with pruritus,
and the two are often clinically inseparable at an early age.
6. An intractable seborrhea-like dermatitis with chronic diarrhea and failure to thrive may reflect systemic dysfunction of the
immune system.
7. A chronic seborrhea-like pattern, which responds poorly to treatment, may also result from cutaneous histiocytic infiltrates
in infants with Langerhans cell histiocytosis X. Seborrheic dermatitis is a common cutaneous manifestation of AIDS in
young adults and is characterized by thick, greasy scales on the scalp and large hyperkeratotic erythematous plaques on the
face, chest, and genitals

5. A patient has presented with enlargement of great toe as shown below given photograph. This is seen in
which condition?

A. Proteus syndrome
C. Tuberous sclerosis

B. Neu-fibromatosis
D. All of the above

5. Ans. D. All of the above

1. Macrodactyly represents an enlargement of the toes and may occur as an isolated problem or in association with a variety
of other conditions such as Proteus syndrome, neurofibromatosis, tuberous sclerosis, and Klippel-Trenaunay-Weber
syndrome.
2. This condition results from a deregulation of growth, and there is hyperplasia of one or more of the underlying tissues
(osseous, nervous, lymphatic, vascular, fibrofatty).
3. Macrodactyly of the toes may be seen in isolation (localized gigantism) or with enlargement of the entire foot.

6. This photograph showing which test?

A. Lachman test
B. Anterior drawer test
C. Lateral pivot shift test D. McMurray test
6. Ans. B. Anterior drawer test

1.
2.

3.

The anterior drawer test detects ACL injuries and is performed with the patient supine and the knee in 90 degrees of
flexion.
The lateral pivot shift test is performed with the patient supine, the hip flexed 45 degrees, and the knee in full extension.
Internal rotation is applied to the tibia while the knee is flexed to 40 degrees under a valgus stress (pushing the outside of
the knee medially).
The McMurray test, used to assess meniscal integrity, is performed with the patient supine and the examiner standing on
the side of the affected knee.

7. Following organism can cause a disease mimicking like which one of the following?

(A). Sarcoidosis
(C). Asthma

(B). Miliary TB
(D). Lung fibrosis

7. Ans. (B). Miliary TB

a. This is Spiked spherical conidia of H. capsulatum. It can cause a disease mimicking like miliary TB.
b. Extra Edge: Coccidiomycosis causes desert rheumatism.
8. Which type of sensory receptor labelled as X? (See Color Atlas, Figure 9)

(A) Nuclear bag fiber

(B) Nuclear chain fiber
(C) Golgi tendon organ
(D) Bare nerve ending
8. The answer is C. Golgi tendon organ
The Golgi tendon organ are present near the tendon, in series to muscle fibres. They senses the force of muscular contraction. The
nuclear chain and bag fibers, along with type Ia endings, are all components of the muscle spindle(shown as Y) which reports muscle
length and velocity of muscle shortening.
9. In the given diagram of brachial plexus identify the nerve denoted as X (See Color Atlas, Figure 4)

A. Median nerve
C. Axillary nerve

B. Radial nerve
D. Ulnar nerve

9. Ans. A) Median nerve

The brachial plexus is a network of nerve fibers, running from the spine, formed by the ventral rami of the lower four cervical and
first thoracic nerve roots (C5-C8, T1). It proceeds through the neck, the axilla (armpit region), and into the arm. The median nerve is
formed from parts of the medial and lateral cords of the brachial plexus, and continues down the arm to enter the forearm with the
brachial artery.
It originates from the brachial plexus with roots from C5, C6, C7, C8, & T1.
10. What is the your diagnosis of the following examination of the fundus?

(A)Retinoblastoma
(B) Optic atrophy
(C) Papilledema
(D) Retinal detachment

10. Ans. (C) Papilledema

It is a cause of papilledema means optic disc edema from raised intracranial pressure. This obese young woman with pseudotumor
cerebri was misdiagnosed as a migraineur until fundus examination was performed, showing optic disc elevation, hemorrhages, and
cotton-wool spots.
This connotes bilateral optic disc swelling from raised intracranial pressure.
Visual field testing shows enlarged blind spots and peripheral constriction (Fig. 28-3F ). With unremitting papilledema, peripheral
visual field loss progresses in an insidious fashion while the optic nerve develops atrophy. In this setting, reduction of optic disc
swelling is an ominous sign of a dying nerve rather than an encouraging indication of resolving papilledema.
11. What is the diagnosis?

a. Epicanthus
c. Cryptophthalmos

b. Microblepharon
d. Coloboma of the lid

11. Ans. a. Epicanthus

a. This is a semilunar fold of skin, situated above and sometimes covering the inner canthus .
b. It is usually bilateral and gives the appearance that the eyes are far apart and have a convergent squint and the bridge of
the nose is flat.
c. It may disappear as the nose develops. It is normal in mongolian races, and deformity can be remedied by plastic surgery.

12. The infant in the following pictures (A) and (B) presented with hepatosplenomegaly, anemia, persistent rhinitis, and a
maculopapular rash. The most likely diagnosis for this child is ?

A
(A). Toxoplasmosis
(B). Glycogen storage disease
(C). Congenital hypothyroidism
(D). Congenital syphilis

12. Ans. (D). Congenital syphilis (Behrman, 16/e, pp 903907..)

The clinical presentation of congenital syphilis is varied. Many newborns appear normal at birth and continue to be asymptomatic
for the first few weeks or months of life. Most untreated infants will develop a skin lesion, the usual one being an infiltrative,

maculopapular peeling rash that is most prominent on the face, palms, and soles. Involvement of the nasal mucous membranes
causes rhinitis with a resultant serous and occasionally purulent, blood-tinged discharge (snuffles).
This, as well as scrapings from the skin lesions, contains abundant viable treponemes. Hepatosplenomegaly and lymphadenopathy
are common, and early jaundice is a manifestation of syphilitic hepatitis. Among the later manifestations, or stigmata, of congenital
syphilis is interstitial keratitis, which is an acute inflammation of the cornea that begins in early childhood (most commonly between
6 and 14 years of age). Interstitial keratitis represents the response of the tissue to earlier sensitization. Findings include marked
photophobia, lacrimation, corneal haziness, and eventual scarring.

13. A 3-year-old girl is admitted with the x-ray pictured. The child lives with her parents and a 6-week-old brother. Her
grandfather stayed with the family for 2 months. The grandfather had a 3-month history of weight loss, fever, and hemoptysis.
Appropriate management of this problem includes (See Fig)

(A).
(B).
(C).
(D).

Bronchoscopy and culture of washings for all family members

Placement of a Mantoux test on the 6-week-old sibling
Isolating the 3-year-old patient for 1 month
Treating the 3-year-old patient with isoniazid (INH) and rifampin

13. Ans. (D). Treating the 3-year-old patient with isoniazid (INH) and rifampin (Behrman, 16/e, pp 885897.)
The key to controlling tuberculosis in children and eradicating the disease is early detection and appropriate treatment of adult
cases; the child, once infected, is at lifelong risk for the development of the disease and for infecting others unless given isoniazid
prophylaxis. The usual source of the disease is an infected adult. Household contacts of a person with newly diagnosed active
disease have a considerable risk of developing active tuberculosis, and the risk is greatest for infants and children. Therefore, when
tuberculosis is diagnosed in a child, the immediate family and close contacts should be tested with tuberculin skin tests and chest
radiographs and treated appropriately when indicated. Bronchoscopy would be indicated only in unusual circumstances. Three to
eight weeks is required after exposure before hypersensitivity to tuberculin develops. This means that the tuberculin test must be
repeated in exposed persons if there is a negative reaction at the time that contact with the source of infection is broken. TB skin
tests are usually negative in infants of this age, even when active disease is ongoing. A logical preventive measure is the
administration of isoniazid to the baby for 3 months when a Mantoux (purified protein derivative, PPD) can then be placed.
Transmission of tuberculosis occurs when bacilli-laden, small-sized droplets are dispersed into the air by the cough or sneeze of an
infected adult. Small children with primary pulmonary tuberculosis are not considered infectious to others, and they are not capable
of coughing up and producing sputum. Sputum, when produced, is promptly swallowed, and for this reason specimens for microbial
confirmation can be obtained by means of gastric lavage from smaller children.

14. True statement about the structure (mycelia) shown below is

A)
B)
C)
D)

Unicellular growth form of fungi

Thread like branching cylindrical tubules
Clumps of intertwined branching hyphae
Reproducing bodies of molds

14. Ans: C) Clumps of intertwined hyphae

Reference: Ananthanarayanan 7th Edition Page 610
Fungi are eukaryotic cells, which lack chlorophyll, and they cannot generate energy through photosynthesis.
o Hyphae are threadlike, branching, cylindrical tubules composed of fungal cells attached end to end. These grow by extending in
length from the tips of the tubules
o Molds (also called as mycelia) are composed of clumps of intertwined tangled mass of branching hyphae. These grow by
longitudinal extension and produce spores
15. the picture below shows feet of a patient, Which of the following is most likely cause?

A. Actinomyces somaliensis
B. Nocardia asteroides
C. Staphylococcus aureus
D. All of the above
15. Ans. C. Staphylococcus aureus.
(Ref. Ananthanarayan Microbiology 8th/pg. 402; H 17th/pg. 998)
Mycetomas are usually caused by fungi but may be caused by bacteria as well.
Even Staph. Aureus and other Pyogenic bacteria like S.pyogenes, Pseudomonas may occasionally cause a mycetoma-like lesion
*(botryomycosis). Bacterial mycetomas are usually caused by actinomycetes Actinomyces (A. israeliii, A. bovis), Nocardia (N.
asteroides, N. brasiliensis, N. caviae), Actinomadura (A. madurae, A. pelletierii), Streptomyces (S. somanliensis).
16. A 25-year-old woman noted increasing numbers of white spots on her scalp hairs 2 weeks earlier. Examination of the hair
shafts showed multiple white nodules completely encircling the hair shafts. The culture grew yellowish to cream fluffy colonies,
this condition is caused by?

A. Piedraia hortae
B. Pityrosporum orbicularia
C. Hortae werneckii
D. Trichosporon beigelii
16. Ans. D. Trichosporon beigelii
(Ref. Ananthanarayan Microbiology 7th ed. 570)
PIEDRA
This refers to colonization of the hair shaft that results in firm, irregular nodules.
If the nodule is dark, the infection is Black Piedra and is due to Piedraia hortae.
The nodule is the ascomycete fruiting body of the fungus, know as an ascostroma.
If the nodule is white, the infection is White Piedra and is due to Trichosporon beigelii.
These nodules are a loose aggregate of hyphae and arthroconidia.
The infection may affect hairs of the scalp, body and genital areas.

17. An aerobic, oxidase positive organism is isolated from the sputum of a 12-year-old cystic fibrosis patient with pneumonia. On
Agar culture the organisms have a "fruity" odor and form greenish colonies. (See Color Altas, Figure-12)
Most likely organism is?

A. Chlamydia pneumoniae
B. Klebsiella pneumoniae
C. P. aeruginosa
D. Serratia marcescens
17. Ans. C.
All of the options are potential etiological agents for pneumonias in humans. The laboratory descriptions of the organism best fits
Pseudomonas aeruginosa

18. A Pap smear from a 30-yr lady demonstrates following pathogen. (See Figure ) Organisms are likely to be

A. Cryptosporidium parvum
C. G. lamblia

B. E. histolytica
D. T. vaginalis

18. Ans. (D)

Protozoan parasite that causes vaginitis is Trichomonas vaginalis. T.vaginalis causes urethritis in males and vaginitis in females and
the infection is sexually transmitted. Females complain of itchy, greenish discharge and the appearance is called as strawberry
appearance. The pH of the vaginal discharge is always >4.5. Diagnosis is made by demonstrating characteristic motility on
microscopic examination (called as twitching or wobbling motility). The drug of choice is metronidazole.

19. An obese 32 year old diabetic women presents with complaint of red and painful skin in her abdominal skin folds.
Examination reveals a creamy white material at the base of the fold. Microscopic examination of the exudates reveals oval
budding structures. The most likely causative agent is:

A. A. fumigatus
C. E. floccosum

B. C. albicans
D. M. canis

19. Ans. (B)

This is the history of intertrigo, which is caused by candida

20. H & E stain of biopsy specimen from an AIDS patient shows spherules with endospores. Lactophenol analine blue
prepraration is also shown below. The most likely organism is

A. B. dermatitidis
C. C. immitis

B. C. albicans
D. C. neoformans

20. Ans. (C)

This is the characteristic tissue apprearance of C. immitis which is dimorphic fungus. This fungus causes desert rheumatism and valley
fever. The infection is diagnosed by demonstrating endosporulating spherule in the infected tissue.