ADrPlexus Digital Strides 2016
NEET PG MOCK 4
1. A young librarian has been exceedingly shy and
fearful of people since childhood. She longs to make
friends, but even casual social interactions cause her a
great deal of shame and anxiety She has never been at
a party, and she has requested to work in the least
active section of her library, even though this means
lower pay She cannot look at her rare customers
without blushing, and she is convinced that they see
her as incompetent and clumsy. Which anxiety
disorder is most likely to be confused with this
personality disorder?
1. Generalized anxiety disorder
2. Specific phobia
3. Agoraphobia
4. Social phobia
Ans. 4
A voidant personality disorder can be difficult to
differentiate from social phobia. One differentiating factor
is that in social phobia specific situations, rather than
interpersonal contact, cause distress and are avoided.
2. Melatonin
1. Is synthesized in the anterior pituitary gland
2. Regulate skin pigmentation in humans
3. Secretion is increased by darkness
4. Secretion is inhibited by norepinephrine from the
sympathetic nervous system
Ans. 3
Synthesis and secretion of melatonin are increased in the
dark via input. from norepinephrine secreted by
postganglionic sympathetic neurons. Melatonin is
synthesized in the pineal gland from the amino acid
tryptophan. Pinealomas (tumors of the pineal gland) that
destroy the pineal gland and reduce secretion of melatonin
and cause hypothalamic damage may cause precocious
puberty by removing the inhibitory effect of melatonin on
the pituitary response to gonadotropin releasing hormone.
Melatonin causes amphibian skin to become lighter in
color but has no role in the regulation of skin color in
humans.
3. Which of the following characteristics of an axon is
most dependent on its diameter?
1. The magnitude of its resting potential
2. The duration of its refractory potential
3. The conduction velocity of its action potential
4. The overshoot of its action potential
Ans. 3
1
The conduction velocity of an action potential along an
axon is proportional to the axon's diameter for both
unmyelinated and myelinated axons. The resting
membrane potential, the duration of the relative refractory
period, and the magnitude of the action potential are
dependent on the type and density of electrically excitable
gates and the ability of the Na to establish and maintain
the concentration gradients. These characteristics are not
related in any systematic way to the axon diameter.
4. The characteristic of a water-insoluble substance
most important in governing its diffusibility through a
cell membrane is its.
1. Hydrated diameter
2. Molecular weight
3. Electrical charge
4. Lipid solubility
Ans. 4
Materials that are not soluble in water can only cross the
membrane through the lipid bilayer. The most important
factor determining how well a substance can diffuse across
the lipid bilayer is the substance's lipid solubility If two
materials have the same lipid solubility, then the
permeability of the smaller particle will be greater.
5. A couple comes to you because they have been
unable to conceive even after 1 year of trying. You
examine the man and notice a darkish mass and
fullness of the left scrotum / spermatic cord compared
to the smaller right scrotum / spermatic cord. You
suspect which of the following?
1. Undiagnosed cryptorchidism of the right testicle
2. Acquired left sided varicocele
3. Acquired left femoral hernia
4. Acquired right direct femoral hernia
Ans. 2
A dark mass within the scrotum would most likely be one
of two things: varicocele or indirect inguinal hernia.
Varicoceles are a stasis of blood within the pampiniform
plexus and generally occur most frequently on the left side
because the testicular vein on the left drains into the
higher pressure left renal vein whereas the right testicular
vein drains into the inferior vena cava. The presence of a
varicocele is associated with reduced fertility
6. Which of the following statements concerning
erection, emission, and ejaculation in the male is
correct?
1. Contraction of the internal urethral sphincter is under
control of the parasympathetic nervous system.
2. The parasympathetic nerves stimulate closure of
helical arteries
3. Sympathetic neurons stimulate the helical arteries to
dilate and increase blood flow to the corpora
cavernosum
4. Contraction of the bulbospongiosus muscles impedes
the drainage of blood from the corpus spongiosum.
Ans. 4
The bulbospongiosus muscle is innervated by the
pudendal nerve (S2-S4) and its contraction helps to keep
blood within the shaft of the penis. Contraction of the
internal urethral sphincter is under control of the
sympathetic nervous system. 'Con-comitant with dilation
of the helicine arteries under parasympathetic innervation,
which allows increased blood to flow into the cavernous
spaces, contraction of the bulbospongiosus and
ischiocavemosus muscles at the base of the cavernous
bodies reduce blood from leaving, resulting in
engorgement and penile or clitoral erection. Emission of
seminal fluid, prostatic secretions, and sperm from the vas
deferens is due to contraction of smooth muscle under
sympathetic control.
7. In a clinical trial, two drugs A and B were
administered to alternate patients in 100 cases of
hypertension and the effect of these two drugs was
studied statistically by applying chi square test. The
value of chi square was 4.12 with degree of freedom
equal to one against the table value of 3.84 at 5% level.
Which of the following conclusions can be drawn from
this study?
1. Null hypothesis is proved
2. There is no significant difference between the effect of
two drugs
3. Null hypothesis is rejected
4. The probability of the effect of the two drugs beings
the same are more than 0.05
Ans. 3
The null hypothesis in this trial is that the two drugs A and
B are equally effective. The calculated chi-square value of
4. I 2 at one degree of freedom on comparison with the
table value of 3.84 indicate the statistically significant
difference between the drug effectiveness.
This also means that the null hypothesis of equality is
rejected at 5% level of significance or P < 0.05.
8. Which of the following contains the ovarian
Neurovascular bundle?
1. Broad ligament
2. Mesosalpinx
3. Mesovarium
4. Suspensory ligament
Ans. 4
The mesosalpinx. mesovarium. and suspensory ligament
are all continuous with the broad ligament .. which is a
reflection of peritoneum over the female reproductive
organs. The mesovarium attaches the ovary to the broad
ligament. The suspensory ligament of the ovary runs from
2
the pelvic brim to the lateral pole of the ovary. It contains
the ovarian artery. ovarian vein, ovarian lymphatics. and
ovarian nerves (ovarian neurovascular bundle). Volvulus
of the ovary (usually associated with an ovarian tumor)
may constrict the neurovascular bundle with marian
infarct and pain referred to the inguinal and hypogastric
regions.
9. Rakesh, 30-yrs has marked swelling on palmar
aspect of the wrist. Persistent flexion of fingers and
apparent shortening of middle finger is seen. There is
paresthesia over palmar aspect of the thumb, index,
middle, and a questionable portion of the ring finger,
yet when wrist is gently flexed, intense pain spreads
over this area. Sensation over palm is normal. Partial
flexion of fingers in this case is best explained by
which of the following?
1. Compression of the radial artery
2. Compression of the recurrent bra ich of the median
nerve
3. Impingement of the flexor tendons by a dislocated
carpal bone
4. Paralysis of the dorsal interossei muscles
Ans. 3
A fall on the extended hand will frequently dislocate the.
lunate bone anteriorly This dislocated bone may then
impinge on the tendons of the extrinsic' digital flexor
muscles and thereby prevent flexiori of the fingers.
Compression of the median nerve in the carpal tunnel
cannot explain this observation because the prime flexors
of the digits are the extrinsic flexors (flexors digitorum
superficialis and profundus). which receive their
innervation in the forearm. well proximal to the injury. The
dorsal interossei. innervated by the ulnar nerve, are digital
extensors. The recurrent branch of the median nerve
innervates the thenar muscles.
10. Paresthesia at anterolateral region of the thigh
may occur in obese persons. It results from an
abdominal panniculus adiposus that bulges over the
inguinal ligament and compresses which underlying
nerve?
1. Femoral branch of the genitofemoral nerve
2. Femoral nerve
3. Iliohypogastric nerve
4. Lateral femoral cutaneous nerve
Ans. 4
The lateral femoral cutaneous nerve passes beneath the
inguinal ligament just medial to the anterior superior iliac
spine. It innervates the lateral aspect of the thigh. The
iliohypogastric nerve innervates a portion of the gluteal.
Inguinal, and pubic regions. The ilioinguinal nerve and the
femoral branch of the genitofemoral nerve supply the
upper portions of the anterior thigh. The sensory
distribution of the femoral nerve is the anterior thigh and
medial leg.
11. Abdominal wall structures that usually contribute
directly to the spermatic cord include:
1. External oblique muscle
2. Falx inguinalis
3. Internal oblique muscle
4. Rectus sheath
Ans. 3
Several abdominal structures are involved in the
formation of the spermatic cord. The deep fascia
contributes the external spermatic fascia. The cremaster
muscle, a contribution of the internal oblique muscle. joins
spermatic cord as the inguinal canal passes through that
layer. The transverses abdominis muscle, which usually
terminates as the falx inguinalis just superior to the deep
ring. contributes to the cremaster muscle in than 5% of all
males. The transversalis fascia contributes the internal
spermatic fascia.
12. Rekha, a 35-year consults an ophthalmologist
because of double vision and droopy eyelids. She also
has complaints of generalized muscle weakness. IV
injection of edrophonium dramatically, but only
briefly, reverses her symptoms. This patient's
probable disease has a pathophysiologic basis that is
closest to that of which of the following conditions?
1. Bullous pemphigoid
2. SLE
3. Idiopathic Addison disease
4. Insulin resistance
Ans. 4
This patient has myasthenia gravis, which was suspected
based on the woman's clinical presentation and confirmed
with the response to the short-acting antichol in esterase
drug edrophonium. Myasthenia gravis is an autoimmune
disease in which antibodies directed against the
acetylcholine receptor of the muscle side of the
neuromuscular junction block the ability of the receptor to
bind to acetylcholil1l.:. Of the diseases listed above. only
insulin resistance IS produced by a similar mechanism, i.e.
antibodies to insulin receptors block the receptors' ability
to bind to insulin. Bullous pemphigoid is caused by
antibodies directed against the basement membrane of the
skin, which damage the basement membrane and cause
blister formation.
Addison diseases are characterized by humoral, and
probably cell-mediated. reactions against the cells in the
endocrine tissue.
SLE has circulating and locally generated immune
complexes mediating the pathophysiology.
13. Normally, the left adrenal venous drainage is into
which of the following?
1. Inferior vena cava
2. Left azygos vein
3. Left inferior phrenic vein
4. Left renal vein
3
Ans. 4
The venous drainage from each adrenal gland tends to be
through a single vein. The left adrenal gland usually drains
into the left renal vein superior to the point where the
gonadal vein enters the left renal vein. The left adrenal
vein usually anastomoses with the hemizygous vein and
may provide an important route of collateral venous
return. The right adrenal gland usually drains directly into
the inferior vena cava.
14. Failure of the sixth aortic arch arteries to form
would lead to loss of blood supply to which of the
following?
1. Right side of the heart
2. Face
3. Thyroid gland
4. Lungs
Ans. 4
Branches of the arteries of the sixth aortic arches form the
pulmonary arteries, In addition the left sixth arch artery
forms the ductus arteriosus. The blood supply to the right
side of the heart is primarily derived from the right and
left coronary arteries and are derived from the right and
left coronary arteries and are derived from the truncus
arteriosus.
The face and thyroid gland receive blood primarily from
the facial and superior thyroid arteries, respectively These
are branches of the common and external carotid arteries
which, in turn, are derivatives of the second and third
aortic arch arteries.
15. Regarding the "pump handle" movement during
respiration, which statement is correct?
1. There is decrease in the anterior -posterior diameter
of the chest
2. No movement occurs at the costovertebral joints
3. There is an increases in the superior -inferior
diameter of the chest
4. Movement occurs at the sternomanubrial joint
Ans. 4
Contraction of the inter costal muscles causes rotation of
the costovertebral joints and elevation of the sternal ends
of the upper (2 to 6) ribs. Along with slight movement of
the sternomanubrial joint, particularly in the young, this
"pump-handle movement" increases the anteroposterior
(AP) diameter of the chest. The transverse diameter of the
thoracic cavity increases when contraction of the
intercostal muscles also elevates the mid portion of the
ribs (bucket-handle movement). Contraction of the
diaphragm increases the vertical diameter of the thoracic
cavity
16. Which of the following hormones interacts with a
cytoplasmic receptor and then localizes in the nucleus
and directs protein and nucleotide synthesis?
1. Thyrotropin - releasing hormone
2. Epinephrine
3. LH
4. Cortisol
Ans. 4
Cortisol, like other steroid hormones, diffuses into target
cells and interacts with intracellular receptors. The
steroid-receptor complex has a high affinity for the
steroid- responsive element of DNA. 'Once bound to DNA,
the hormone-receptor complex acts as a transcription
factor to regulate gene expression and formation of
specific messenger RNAs.
17. Secondary suturing of third degree perineal tear:
1. Should be done two weeks after delivery
2. Should be done one month after delivery
3. Should be done three months after delivery
4. Can be done any time after delivery
Ans. 3
Secondary suturing of third degree perineal tear should
be done three months after delivery.
In third degree perineal tear there is tear of perineal body
involving the sphincter ani extern us with or without
involvement of the anorectal mucosa. It is also called
complete perineal tear. In first degree tear there is
laceration of remnants of hymen, the fourchette, lower
part of vagina and the perineal skin but the perineal body
is intact. In second-degree tear there is laceration of
posterior vaginal wall and varying degree of tear of
perineal body excluding the anal sphincter. A third degree
perineal tear is called old when passed beyond an
arbitrary period of 3 month following the injury. The main
cause of third degree perineal tear' is mismanaged 2nd
stage of labour.
Treatment:
The definitive surgery is repair of the perineal tear with
restoration of perineal body. It should be done between 3-
6 months after the injury. However the best I time is
within 24 hours of injury. By three months the local
infection subsides and the general condition of the patient
improves and if kept more than 6 months' then there more
fibrosis on the margins. Surgery is done by flap method.
18. Repetitive stimulation of a skeletal muscle fiber
will cause an increase in contractile strength because
repetitive stimulation causes an increase in which of
the following?
1. The duration of cross-bridge cycling
2. The concentration of calcium in the myoplasm
3. The magnitude of the end-plate potential
4. The number of muscle myofibrils generating tension
Ans. 1
Each time a skeletal muscle fiber is stimulated by an alpha
moto neuron, enough Ca2+ is released from its
sarcoplasmic reticulum (SR) to fully activate all the
troponin within the muscle. Therefore, every cross bridge
4
can contribute to the generation of tension. However, the
transmission of force from the cross bridges to the tendon
(or bone or measuring device)" does not occur until the
series elastic component (SEC) of the muscle is stretched.
Repetitive firing increases the amount of SEC stretch by
maintaining cross-bridge cycling for a longer period of
time. Repetitive firing increases neither the concentration
of Ca2+ within the myoplasm, the number of myofibrils that
are activated, nor the magnitude of the end-plate potential.
Because all of the cross bridges are activated each time a
skeletal muscle fiber is activated, an increase in Ca2+
concentration would have no effect on muscle strength.
19. The alpha rhythm appearing on an
electroencephalogram has which of the following
characteristics?
1. It produces 20 to 30 waves per second
2. It disappears when a patient's eyes open
3. It is replaced by slower, larger waves during REM
sleep
4. It is associated with deep sleep
Ans. 2
In a totally relaxed adult with eyes closed, the major
component of the electroencephalogram (EEG)' will be a
regular pattern of 8 to 12 waves per second, called the
alpha rhythm. The alpha rhythm disappears when the eyes
are opened. It is most prominent in the parieto-occipital
region. In deep sleep, the alpha rhythm is replaced by
larger, slower waves called delta waves. In REM sleep, the
EEG will show fast, irregular activity
20. A young woman had a repeat lower segment
caesarean section at term. On the sixth postoperative
day her clothes were soaked by serosanguineous
discharge from the abdominal wound. The most likely
diagnosis is:
1. Vesico-cutaneous fistula
2. Uretero-cutaneous fistula
3. Faecal fistula
4. Wound dehiscence
Ans. 4
Discharge of serosanguinous. fluid indicates wound
dehiscence. In vesicocutaneous or urethrocutaneous is
fistula there is discharge of urine from the fistula. In faecal
fistula there is discharge of faecal material from the fistula.
21. A 29-yrs-old man is brought to the emergency
room after a traffic accident causing a traumatic brain
injury. Within several hours he begins eating objects
such as paper, is unable to maintain attention, and
displays increased sexual activity. This occurs due to
bilateral lesions of which of the following regions of
the brain?
1. Temporal lobe
2. Hypothalamus
3. Olfactory lobe
4. Hippocampus

Ans. 1
The Kluver-Bucy syndrome is produced in animals by
removal of the amygdala from both temporal lobes. The
syndrome is characterized by a tendency to examine
objects orally and excessive sexual behavior. The full
syndrome is rarely encountered in humans but many of its
characteristics are observed in patients with bilateral
'temporal lobe lesions produced by encephalitis or
traumatic injury
22. An otherwise healthy 44-year-old man with no
prior medical history has had increasing back pain
and right hip pain for the past decade. The pain is
worse at the end of the day. On physical examination
he has bony enlargement of the distal interphalangeal
joints. A radiograph of the spine reveals the presence
of prominent osteophytes involving the vertebral
bodies. There is sclerosis with narrowing of the joint
space at the right acetabulum seen on a radiograph of
the pelvis. Which of the following diseases is he most
likely to have?
1. Gout
2. Rheumatoid arthritis
3. Osteoarthritis
4. Osteomyelitis
Ans. 3
CORRECT 3. Degenerative osteoarthritis is a common and
progressive condition that becomes more frequent and
symptomatic with aging. There is erosion and loss of
articular cartilage with joint space narrowing. There is
minimal inflammation.
Incorrect 1 gouty arthritis is more likely to be
accompanied by swelling, and deformity with joint
destruction. The pain is not related to usage.
Incorrect 2. Rheumatoid arthritis typically involves small
joints of the hands and feet most severely, and there is a
destructive pannus that leads to marked joint deformity.
Incorrect 4. Osteomyelitis represents an ongoing infection
that produces marked bone deformity, not just joint
narrowing.
23. An 80-year-old woman has had no major medical
problems, but she has never been physically active for
most of her life. One day she falls out of bed and
immediately notes a sharp pain in her left hip. She is
subsequently unable to ambulate without severe pain.
Radiographs show not only a fracture of the left
femoral head, but also a compressed fracture of T10.
Which of the following conditions is she most likely to
have?
1. Vitamin D deficiency
2. Acute osteomyelitis
3. Osteogenesis imperfect
4. Osteoporosis
Ans. 4
5
CORRECT 4. She most likely has osteoporosis of bone with
accelerated bone loss leading to the propensity for
fractures. Physical inactivity further accelerates bone loss
and decreases muscle mass and agility that contribute to
falls.
Incorrect 1. A poor diet could be lacking in vitamin D,
though endogenous vitamin D production occurs with
sunlight exposure. The findings are those of osteomalacia
and are similar clinically to osteoporosis.
Incorrect 2. An osteomyelitis is not typical at this age and
does not usually present as fractures in multiple locations.
Incorrect 3. This inherited disorder of collagen synthesis is
initially diagnosed in fetuses and young children.
24. A 10-yrs-old boy displays hyperactivity and is
unable to focus on his schoolwork because of an
inability to focus on the activity. Which of the following
drugs might prove effective for relieving the boy's
main symptoms?
1. Methylphenidate
2. Terbutaline
3. Dobutamine
4. Pancuronium
Ans. 1
Methylphenidate is similar to amphetamine and acts as a
CNS stimulant, with more pronounced effects on mental
than on motor activities. It is used to treat narcolepsy and
attention-deficit hyper activity disorders.
25. Decubitus ulcer in a case of prolapse uterus occurs
mainly due to:
1. Infection
2. Friction
3. Venous congestion
4. Malignant change
Ans. 3
Decubitus ulcer in prolapsed uterus is due to venous
congestion. Friction does not play any major role. Though
in 13th edition of Shaw friction is mentioned as a cause but
in previous edition the main emphasis has been placed on
venous congestion. Please read the earlier editions for
details.
26. We administer hexamethonium to a subject. He is
in the supine position. Which of the following
responses would you expect in response to this drug?
1. Bradycardia
2. Increased GI tract motility
3. Increased salivary secretions
4. Vasodilation
Ans. 4
Hexamethonium is an autonomic ganglionic blocking drug.
So by blocking neurotransmission across all autonomic
ganglia (and activation of the adrenal medulla), we
essentially denervate distal structures. Now we observe
how things change.
For the structures and functions listed (and several others
that weren't), it is the parasympathetic nervous system
that exerts the predominant resting tone. Only control of.
vascular smooth muscle tone (and, therefore, of blood
pressure) is primarily regulated by the sympathetic
nervous system.
Block the ganglia and vasodilation will occur as
predominant SNS influences are removed. As far as the
other structures go-all of which are mainly influenced by
the PNS at rest-we would observe a rise of heart rate,
decreases of bladder and gut tone (e.g. reduced tone of the
bladder detrusor and longitudinal muscles of the gut),
mydriasis, and, reduced salivary secretions (xerostomia).
Sweat gland secretions, which also have pre dominant
sympathetic control, would decrease too.
27. A 26-yrs-old woman with reactive depression
complains of missing her period and having milk
discharge from her breasts. Pregnancy tests are
negative. Which of the following is most likely to have
caused these findings?
1. Amoxapine
2. Clomipramine
3. Fluoxetine
4. Sertraline
Ans. 1
Amoxapine a tricyclic antidepressant, effectively , blocks
neuronal norepinephrine reuptake, is somewhat less
potent in terms of blocking serotonin uptake, and is far
less potent in terms of blocking dopamine reuptake.
A metabolite of amoxapine blocks dopamine receptors
quite well, and that effect makes it the most likely choice as
the drug that caused the patient's menstrual irregularities
and galactorrhea. You should recall that such drugs as the
phenothiazine, which exert their main antipsychotic
effects via blockade of dopamine receptors, may also cause
amenorrhea galactorrhea by the same mechanism, and
drugs that activate dopamine receptors (e.g.,
bromocriptine) can be used to manage this endocrine
dysfunction. Amoxapine's dopamine receptor blockade
also seems to account for why the drug exerts some
antipsychotic properties, theoretically making it useful for
patients with both psychosis and depression.
28. All of the following physiological or biochemical
effects require progesterone except:
1. Stimulation of myometrial contraction
2. Promotion of differentiation and growth of lactiferous
ducts
3. Formation of cortisol by foetal adrenal cortex in early
pregnancy
4. Formation of aldosterone by the foetal adrenal cortex
in early pregnancy
Ans. 1
Progesterone inhibits myometrial contraction.
Pregesterone relaxes smooth muscles and hence relax
uterus in pregnancy. It causes myohyperplasia and hence
6
increase the strength but diminish the frequency of uterine
contraction, Rest of three statements are correct.
29. An SSRI antidepressant (eg. Fluoxetine) will be
prescribed for an adult patient. You should advise him
or her that two most likely side effects or adverse
responses that may eventually occur at therapeutic
blood levels are which of the following?
1. Intense dizziness upon standing and palpitations.
2. Migraine headache and involuntary skeletal muscle
twitching
3. Polyuria and insatiable thirst
4. Sexual dysfunction and weight gain.
Ans. 4
Sexual dysfunction (probably of CNS origin) and weight
gain (sometimes significant) are relatively common
problems associated with SSRI therapy Orthostatic
hypotension and . reflex tachycardia sometimes occur with
older antidepressants (tricyclics, e.g. imipramine), but are
rare with SSRIs. Migraine is not likely; blockade of
serotonin reuptake might actually reduce the .risk (note
that triptans exert antimigraine actions by acting as
serotonin agonists). Lithium is the drug likely to cause
polyuria and polydipsia. None of the other side effects or
adverse responses listed in the question are likely with an
SSRI.
30. Na+ is reabsorbed from the basolateral surface of
the renal epithelial cells by which of the following?
1. Na/H exchange
2. Na-glucose cotransport
3. Na-K pump
4. Facilitated diffusion
Ans. 3
The intracellular Na concentration of renal epithelial cells
is pumped out of renal epithelial cells by Na- K pumps
located on the basolateral surface of the epithelial cells.
The Na/H exchanger and the Na- glucose transporter are
located on the apical surface of the epithelial cells. Na + is
transported from the peritubular spaces to the capillaries
by solvent drag.
31. Glomerular filtration rate would be decreased by
which of the following?
1. Constriction of the efferent arteriole
2. An increase in afferent arteriolar pressure
3. Compression of the renar capsule
4. A decrease in the concentration of plasma protein
Ans. 3
GFR will decrease is there is a decrease in the net
glomerular capillary pressure or the flow of fluid through
the glomerulus. The net glomerular capillary pressure (for
Starling forces) is equal to the glomerular capillary
pressure minus the sum of the plasma oncotic pressure
and intrarenal pressure. Compression of the renal capsule
increases the intrarenal pressure and therefore decreases
the net capillary filtration pressure. Constriction of the
efferent arteriole increases glomerular capillary pressure. 35. Drug Causing anaphylactoid reaction:
Decreasing the concentration of plasma protein will 1. Propofol
decrease the plasma oncotic pressure and lead to an 2. Alcuronium
increase in GFR. 3. Thiopentone
4. Glycopyrrolate
32. Mendelson syndrome is due to:
1. Aspiration pneumonitis Ans. 2
2. Chemical pneumonitis Development of true allergy or antibody formation may
3. Esophagitis of course occur in days or weeks following exposure to any
4. Esophageal spasm of non depolarising muscle relaxants (i.e. ALCURONIUM)
They also cause TACHYPHYLAXIS.
Ans. 1
Mendelson's syndrome is acid aspiration syndrome. 36. Which of the following is a function of cells
Aspiration of acid gastric contents cause a chemical Labelled A ?
trauma to bronchial and alveolar epithelia i.e. acute
exudative pneumonitis
Mendelson's. syndrome usually occur with material
(gastric acid) at a pH of 2. 5 or below, but known. to occur
with fluid of a neutral r" as well.

33. The supraoptic nucleus of the hypothalamus is

believed to control secretion of which of the following
hormones?
1. Antidiuretic hormone
2. Oxytocin
3. Growth hormone
4. Adrenocorticotropic hormone
1. Secretion of FSH into the tubular lumen
Ans. 1 2. Secretion of testosterone into the tubular lumen
Secretion of antidiuretic hormone (ADH) and oxytocin by 3. Maintenance of the blood-testis barrier
the neurohypophysis is regulated in the hypothalamic 4. Synthesis of estrogen after puberty
supraoptic and paraventricular nuclei, respectively. This
hypothalamic control of secretion of pituitary hormone Ans. 3
(inhibitory as well as releasing) in the case of the
neurohypophysis is by direct neural connection, and, in the Of course If you focus on the Picture without reading
case of the adenohypophysis, by humoral factors conveyed the options you cannot guess the StructureSo
bya microcirculation known as the hypothalamic- Whenever you are not sure about the HISTOLOGY
hypophyseal portal system. Picture, read the options and almost 99% you can get
to know the structure
34. Which of the following is the principal steroid Picture : Structure of Seminiferous tubule
secreted by the fetal adrenal cortex?
1. Cortisol
2. Corticosterone y
3. Dehydroepiandrosterone
4. Progesterone

Ans. 3
Because it lacks 3-dehydroxysteroid, the enzyme that
converts pregnenolone to progesterone (the initial step in
both glucocorticoid and mineralocorticoid synthesis), the
fetal cortex synthesizes primarily
dehydroepiandrosterone. This steroid is released as its
sulfate and is metabolized further to estrogen and
androgen by the placenta. During fetal life, the adrenal
cortex consists of a thin subcapsular rim, which eventually
gives rise to the adult cortex, and a thick inner fetal cortex,
which constitutes 80% of the gland. This zone undergoes
rapid involution after birth.

7
The Sertoli cells rest on a basal lamina and form a layer
around the periphery of the seminiferous tubules. They are
attached to each other by specialized junctional complexes
that limit the movement of fluid and solute molecules from
the interstitial space and blood to the tubular lumen, and
thus form a blood testis barrier that provides an
immunologically privileged environment for sperm
maturation. Sertoli cells are intimately associated with
developing spermatozoa and play a major role in germ-cell
maturation. They secrete a variety of serum proteins and
an androgen protein into the tubular fluid in response to
FSH and testosterone stimulation. Testosterone is
synthesized and secreted by the interstitial Leydig cells.
Estrogen is produced in small amounts by the Sertoli cells
before puberty.
37. Astigmatism is:
1. Defect in curvature
2. Defect in thickness of cornea
3. Defect in refractive index
4. Defect in opacity of lens
Ans. 1
Astigmatism It is that condition of refraction wherein a
point focus of light cannot be formed' upon the retina. It
includes those anomalies in the optical system wherein an
appreciable error is caused by the unequal refraction of
light in different meridians. Hence it may be an error
either of curvature, of centering or of refractive index.
There fore this question is controversial as both the
options are given. But since the commonest form of
astigmatism is due to curvature defect, this will be the
answer.
38. A 10-yrs-old girl with type I diabetes develops a
neuropathy limited to sensory neurons with free
nerve endings. Quantitative sensory testing will reveal
higher-than-normal thresholds for the detection of
which of the following?
1. Fine touch
2. Vibration
3. Pressure
4. Temperature
Ans. 4
Free nerve endings contain receptors for temperature,
pain, and crude touch. However, fine touch, pressure, and
vibration are detected by nerve .endings contained within
specialized capsules that transmit the stimulus to the
sensory receptors. Muscle length is encoded by the
primary' nerve endings of Ia fibers, which are located on
intrafusal fibers within the muscle spindle.
39. Hypothermia is used in all except:
1. Neonatal asphyxia
2. Cardiac surgery
3. Hyperthermia
4. Arrythmia
8
Ans. 4
There is substantial protection against ischemia and
hypoxia is provided by. just 1-3C hypothermia.
Hypothermia reduces the tissue metabolic rate about
8%/OC.
It decreases the cerebral metabolic rate and is
cerebroprotective during episode of cerebral ischemia The
protection afforded by mild hypothermia is so great that
reduced core temperature 34 probably indicated in
- Carotid artery surgery
- Neurosurgery
- Procedures where tissue ischemia can be
anticipated
- Traumatic brain injury
- ARDS
- Malignant hyperthermia .
Hypothermia is used in cardiac surgery as cooling does
slow heart and greatly depresses body metabolism .
Dysrhythmia occurs at temperature below 30C,
spontaneous ventricular fibrillation may be seen but is not
likely above 28C. So hypothermia is arrhythmogenic.
40. Which of the following receptors is responsible for
measuring the intensity of a steady pressure on the
skin surface?
1. Pacinian corpuscle
2. Ruffini ending
3. Merkel's disk
4. Meissner's corpuscle
Ans. 2
The Ruffini ending is a tonic receptor that produces a train
of action potentials proportional to the intensity of
pressure applied to the skin. The Pacinian corpuscle is a
very rapidly adapting receptor that fires once or twice in
response to skin deformation. It can produce a continuous
train of action potentials if the stimulus is repetitively
applied and withdrawn. Therefore, the Pacinian corpuscle
is used to encode vibration.
41. Inert particles are sensitized with either antigen or
antibody. Which of the following tests is used
extensively to detect microbial antigens rapidly (five
minute or less)?
1. Coagglutination (COA)
2. Counter immune electrophoresis (CIE)
3. Enzyme-linked immunosorbent assay (ELISA)
4. Latex agglutination
Ans. 4
Of the many methods available for antigen and antibody
detection, LA, ELISA, RIA, CIE, and COA are the most widely
used. Latex agglutination (LA) employs latex polystyrene
particles' sensitized by either antibody or anti gen. LA is
more sensitive than CIE and COA but slightly less sensitive
than either RIA or EIA. LA has been used to detect H.
influenzae, Neisseria meningitidis, and S. pneumoniae
antigens in cerebrospinal fluid. LA has also been used for
detection of cryptococcal antigen. Most recently, LA has
been widely used for rapid detection of group. A
streptococcal antigen directly from the pharynx. The test is
rapid (five minutes), sensitive (approximately 90%), and
specific (99%).
42. The obstetric conjugate diameter is the distance
between the sacral promontory and the:
1. Nearest point on the posterior surface of the
symphysis pubis
2. Upper part of the inner surface of the symphysis pubis
3. Apex of the pubic arch
4. Ilio-pectineal eminences
Ans. 1
Obstetric conjugate is the distance between the sacral
promontory and the .nearest point on the posterior surface
of the symphysis pubis.
Important points:
1. Obstetric conjugate measures 10 cm, It cannot be
clinically measured but is to be inferred from diagonal
conjugate or by lateral radiopelvimetry.
2. True/anatomical conjugate is the distance between
midpoint of sacral promontory to the inner margin of CT.
upper border of symphysis pubis. It measures 11 cm, Its
measurement is inferred by subtracting 1.2 cm from ft
diagonal conjugate.
3. Diagonal conjugate is the distance between the lower
border of symphysis pubis to the midpoint on the s
promontory. It is measures 12 cm. It is measured clinically
during pelvic assessment.
4. Obstetric conjugate can be calculated by subtracting 1.5-
2 cm from the diagonal conjugate.
43. Elevated IgG and IgM antibody titers to parvovirus
suggest a diagnosis of which one of the following?
1. Acute Lyme disease
2. Fifth disease
3. Possible hepatitis B infection
4. Possible subacute sclerosing pan encephalitis
Ans. 2
B. burgdorferi, the causative agent of Lyme disease, elicits
an acute antibody response. IgM appears within days to a
few weeks following tick bite, and 19G appears a few
weeks later. 19G persists; IgM does not. Cross-reactions
occur with other treponemes.
Fifth disease is a viral exanthema commonly seen in
children 8 to 12 years old. Children are ill for a few days
but recover without incident. Unfortunately, if a pregnant
female acquires the disease in the first trimester of
pregnancy, the fetus is at risk. The causative agent is
thought to be a Parvovirus (Parvovirus B 19).
44. A patient has developed an acute congestive
glaucoma in his right eye. The prophylactic measure to
be taken in the fellow eye is:
1. Topical steroids
2. Peripheral iridectomy
9
3. Antibiotics
4. Laser iridotomy
Ans. 4
45. Which one of the following aids is helpful in the
diagnosis of bowel strangulation?
1. Marked abdominal distension
2. Persistent local tenderness
3. Profuse vomiting
4. Multiple air fluid levels on X-ray
Ans. 2
Steady severe pain without quiescent periods is usually
indicative of strangulation.
In non strangulated obstruction of intestine there ma be an
area of localized tenderness at the site of obstruction; in
strangulation there is always localized tenderness
associated with rigidity/rebound tenderness.
Rest of three conditions may be present in both
obstruction as well as strangulation. The presence of shock
indicates ischaemia of bowel. In strangulation pain is
never completely absent.
Remember the following important points about intestinal
obstruction and strangulation:
- Four cardinal symptoms and signs of intestinal
obstruction are crampy abdominal pain, vomiting,
obstipation and abdominal distention. The finding of
localized tenderness, fever, tachycardia and leukocytosis are
supportive of: but not diagnostic for strangulation.
46. Which statement regarding transmission of viral
illness through homologous blood transfusion is true?
1. The most common viral agent transmitted via blood
transfusion is HIV
2. Blood is routinely tested for CMV because CMV
infection is often fatal
3. The most frequent infectious complication of blood
transfusion continues to be viral meningitis
4. Up to 10% of those who develop post transfusion
hepatitis will develop cirrhosis or hepatoma or both.
Ans. 4
CMV is harbored in blood leukocytes. While acute CMV
infection may cause transient fever, jaundice, and
hepatosplenomegaly in cases of large blood donor
exposures, post transfusion l.CMV infection
(seroconversion) is not a significant clinical problem in
immunocompetent recipients, and therefore blood is not
routinely tested for the presence of CMV Post transfusion
non-A, non-S hepatitis, however, not only represents the
most frequent infectious complication of transfusion but
also is associated with an incidence of chronic active
hepatitis up to 16% and an 8 to 10% incidence of cirrhosis
or hepatoma or both. The etiologic agent in over 90% of
cases of post transfusion hepatitis has' been identified as
hepatitis C.
47. A 60-yrs-old diabetic man undergoes resection of
an infected boil on his back. The wound is left open for
packing and cleansing. Week by week, the wound
grows smaller. Which of the following is true
concerning wound contracture?
1. It is the primary process affecting closure of a sutured
or stapled surgical wound
2. Bacterial colonization significantly slows the process
of contraction
3. It may account for a maximum of 50% decrease in the
size of a wound
4. It is based on specialized fibroblasts that contain actin
myofilaments
Ans. 4
While epithelialization is responsible tor the healing of a
closed incision, wound contraction is the primary method
of closure in open wounds. During this process, the skin
surrounding the wound is pulled over the wound surface
and may account for up to a 90% reduction in the size of
an open wound. In areas of greater adherence of skin to
underlying tissue, the ability of contraction to close the
wound is hindered due to the decreased mobility of the
skin, Therefore, in areas of tight skin adherence such as the
leg, contraction may only account for- 30 to 40% reduction
in wound size. Fibroblasts in the open wound, which
predominate during the proliferative phase, contain
increasing numbers of actin microfilaments, thereby
becoming myofibroblasts, These specialized fibroblasts are
thought to be responsible tor wound contraction either
through intrinsic cellular contraction or attachment to
collagen strands.
48. A 35-yrs-old woman complains of attacks
of breathlessness, cyanosis and flushing. Apart
from occasional diarrhea she has no
abdominal symptoms. Abdominal examination
reveals an enlarged nodular liver. If
laparotomy is done, we could expect to find:
1. An ovarian tumor
2. A multicentric hepatoma
3. An appendicular carcinoid
4. Crohn's disease
Ans. 3
History of breathlessness, cyanosis and flushing points
towards carcinoid syndrome. Enlarged nodular liver
means hepatic metastasis, which is essential to produce
carcinoid syndrome.
Appendicular carcinoids are detected in I in ever) 200-300
appendicectomies. It is one of the commonest sites for
carcinoid tumours.
Carcinoid tumours are commonly seen in appendix, small
intestine, lungs, stomach etc.
Flushing, diarrhoea, wheezing, pellagra like skin lesions
are the common features.
Carcinoid tumours secrete large amount of serotonin.
Treatment is with somatostatin analogues like octreotide,
10
lanreotide etc. Surgery is done whenever possible to
remove the tumours.
49. Following blunt abdominal trauma, A 2 year old
girl develops upper abdominal pain and vomiting. An
upper gastrointestinal series reveals a total
obstruction of the duodenum with a coiled spring
appearance in the second and third portions.
Appropriate management is
1. Gastrojejunostomy
2. Nasogastric suction and observation
3. Duodenal resection
4. Duodenojejunostomy
Ans. 2
Duodenal hematomas result from blunt abdominal trauma.
They present as a high bowel obstruction with abdominal
pain and occasionally a palpable right upper quadrant
mass An upper gastrointestinal series is almost always
diagnostic with the classic coiled. spring appearance of the
second and third portions of the duodenum secondary to
the crowding of the valvulae conniventes (circular folds)
by the hematoma. Nonsurgical management is the
mainstay of therapy because the vast majority of duodenal
hematomas resolve spontaneously Simple evacuation of
the hematoma is the operative procedure of choice.
However, bypass procedures and duodenal resection have
been performed for this problem. In patients with
duodenal obstruction from the superior mesenteric artery
syndrome, the obstruction is usually the result of a marked
weight loss and, in conjunction with this, loss of the
retropentoneal fat pad that elevates the superior
mesenteric artery from the third and fourth portions of the
duodenum. Nutritional repletion and replenishment of this
fat pad will elevate the artery off the duodenum and
relieve the obstruction.
50. A 42- year old man is undergoing chemotherapy
after resection of a cecal adenocarcinoma with
positive lymph nodes. Which of the following
potentially operable complications is a common
occurrence among patients receiving systemic
chemotherapy?
1. Acute cholecystitis
2. Perirectal abscess
3. Appendicitis
4. Diverticulitis
Ans. 2
A surgeon is frequently asked to evaluate patients who are
receiving systemic chemotherapy Most complications of
chemotherapy do not require surgical therapy. Perirectal
abscesses are more common in these immunosuppressed
patients. 'Gastrointestinal bleeding occurs secondary to
mucosal irritation and thrombocytopenia, Pancreatitis is
uncommon, but is associated with L-asparaginase use. Up
to 20% of patients treated with floxuridine by continuous
hepatic artery infusion develop some degree of
inflammation and obstruction of the bile duct. Systemic
chemotherapy does not increase the likelihood of acute
cholecystitis. appendicitis, incarcerated femoral hernia, or
diverticulitis.
51. The operation of choice for the below condition
1. Division of annular ring
2. Gastrojejunostomy
3. Duodenojejunostomy
4. Pancreaticoduodenal tom
Ans. 3
The treatment of annular pancreas is duodenojejunostomy
or gastrojejunostomy either of which bypasses the
obstruction.
According to Bailey and Love duodenoduodenostomy or
duodenojejunostomy are usual operation. Obstructing
pancreatic ring must not be simply divided. Since this may
not relieve the obstruction and pancreatic fistula may
result.
Annular pancreas is formed by a thin band of normal
pancreas tissue that completely encircles the second
portion of duodenum and is continuous with head of
pancreas anteriorly and posteriorly. 40% patients have
associated duodenal stenosis or atresia.
Symptoms of duodenal obstruction (gastric distention and
vomiting) occur in about one third of cases in the first
week of life and about one half of cases in the first year.
Rests are asymptomatic until adulthood, when abdominal
pain, nausea and vomiting may occur.
52. A patient with mild skin pigmentation comes to
you because of sudden abdominal pain, fever and a
rigid abdomen. Her lab report show blood sugar of 55,
Na of 119, and K of 6.2. Her BP is 88/58. She undergoes
an exploratory laparotomy. Which of the following
statement is true?
1. Treatment with exogenous steroids is usually
ineffective
2. This condition is commonly seen as a consequence of
metastasis of distant cancers, such as lung or breast to
the a al glands
3. Death from untreated chronic adrenal insufficiency
may occur within hours of surgery
11
4. The most common underlying cause today is infection
with MDR tuberculosis
Ans. 3
Failure to recognize adrenal cortical insufficiency,
particularly in the postoperative patient, may be a fatal
error that is especially regrettable because therapy
(exogenous steroids) is effective and easy to administer.
Adrenal insufficiency may occur in a host of settings
including tuberculosis (formerly the most common cause),
autoimmune states" severe infections, (classically,
meningococcal septicemia), pituitary insufficiency, after
burns, during anticoagulant therapy, and-most commonly
today-after interruption of chronically ,administered
exogenous steroids. Although the adrenal gland is an
occasional site for distant metastases, such as from lung or
breast, it is rare for there to be enough destruction of the
glands to produce clinical adrenal insufficiency Chronic
adrenal insufficiency (classic Addison's disease) should be
recognizable preoperatively by the constellation of skin
igmentation, weakness, weight loss, hypotension, nausea,
vomiting, abdominal paib hypoglycemia, hyponatremia,
and hyperkalemia. ' Death may occur within hours of
surgery if a patient with Addison's disease is operated on
without cognizance of adrenal insufficiency and
pretreatment with exogenous steroids. Patients who have
adrenal insufficiency as a result of interruption of
chronically administered exogenous steroids may not
develop the classic electrolyte abnormalities until the
preterminal period. Adrenal insufficiency may also
develop insidiously in the postoperative period,
progressing over a course of several days. This insidious
course is seen when adrenal injury occurs in the
perioperative period, as would be the case with adrenal
damage from hemorrhage into the gland in a patient
receiving postoperative anticoagulant therapy
Measurement of blood corticosteroid levels, urinary
corticosteroid secretion, urinary sodium levels, and
response to exogenous steroids is helpful in establishing
the diagnosis of adrenal insufficiency
53. A 70- year old woman has, vomiting abdominal
distension and episodic crampy midabdominal pain.
She has no history of previous surgery. Her abdominal
radiograph reveals a spherical density in the right
lower quadrant. Correct treatment should consist of
1. Ileocolectomy
2. Cholecystectomy
3. IIeotomy and extraction
4. Nasogastric tube decompression
Ans. 3
Gallstone ileus is due to erosion of a stone from the
gallbladder into the gastrointestinal tract (most commonly
the duodenum). The stone becomes lodged in the small
bowel (usually in the terminal ileum) and causes small-
bowel obstruction. Plain films of the abdomen that
demonstrate small-bowel obstruction and air in the biliary
tract are diagnostic of the condition. Treatment consists of
ileotomy, removal of the stone, and cholecystectomy if it is
technically safe. If there is significant inflammation of the
right upper quadrant, ileotomy for stone extraction
followed by an interval cholecystectomy is often a safer
alternative. Operating on the biliary fistula doubles the
mortality rate compared with simple removal of the
gallstone from the intestine.
54. A 24-yrs-old male, who has been having fever for
15 days, starts having acute pain and distension of
abdomen. Abdominal examination reveals generalized
tenderness with guarding. The most likely diagnosis is:
1. Acute appendicitis
2. Acute pancreatitis
3. Enteric perforation
4. Duodenal ulcer perforation
Ans. 3
The clinical picture described is classical of enteric
perforation and peritonitis.
In enteric fever ulcers occur in intestine, which may
perforate if not treated properly. This complication is seen
in third or fourth week of fever. It is a life threatening
complication and urgent medical and surgical intervention
is required;
GIT haemorrhage is another life threatening complication
of enteric fever that occurs in third or fourth week of fever.
In acute appendicitis and acute pancreatitis abdominal
pain is the main feature rather than fever of 15 days
duration. In DU perforation fever is absent.
55. A neonate is found to have a condition as shown
below. You recommend studies to search for other
anomalies. Associated abnormalities include which of
the following?
1. Abnormalities of the cervical spine
2. Hydrocephalus
3. Duodenal atresia
4. Heart disease
Ans. 4
Congenital anorectal anomalies are frequently associated
with other congenital anomalies including heart disease;
esophageal atresia; abnormalities of the lumbosacral
spine; double urinary collecting systems; hydro nephrosis;
and communication between the rectum and the urinary
12
tract, vagina, or perineum They occur in approximately 1
in 2000 live births. Depending on the type of anomaly
(whether the rectum ends above or below the level of the
levator ani complex), a variety of surgical procedures has
been devised to treat the problem.
However, even when anatomic integrity is established, the
prognosis for effective toilet training is poor in 50% of
cases continence is never achieved. Cervical spine
abnormalities, hydrocephalus, duodenal atresia, and
corneal opacities have no significant association with
congenital anorectal anomalies.
56. A 63-yrs-old man is having facial swelling
What condition is the most likely cause of these
findings?
1. Histoplasmosis
2. Substernal thyroid
3. Thoracic aortic aneurysm
4. Bronchogenic carcinoma
Ans. 4
Superior vena cava obstruction is almost always due to
malignancy and, in three out of four cases, results from
invasion of the vena cava by bronchogenic carcinoma.
Lymphomas account for most of the remaining cases of the
superior vena cava syndrome Fibrosing mediastinitis as a
complication of histoplasmosis or ingestion of
methysergide may occur but is rare.' Rarely a substernal
thyroid or thoracic aortic aneurysm may be responsible
for the obstruction.
Although constrictive pericarditis may decrease venous
return to the heart, it does not produce obstruction of the
superior vena cava. Whatever the cause of the superior
vena cava syndrome, the resultant increased venous
pressure produces edema of the upper body, cyanosis,
dilated subcutaneous collateral vessels in the chest, and
headache. Cervical lymphadenopathy may also be present
as a result of either stasis or metastatic involvement, When
carcinoma is the cause of the superior vena cava
syndrome, the treatment is usually palliative and consists
of diuretics and radiation.
57. Spinal Anesthesia should be injected into the space
between:
1. T12-L1
2. L3 L4
3. L1_ L2
4. L5-S1
Ans: (2)
The LA is injected in the sub arachnoid space
between L2-L3 or L3-L4.
Spinal cord extends from medulla oblongata to lower
border of L, in adult.
Spinal; cord extends from medulla oblongata to
lower border of L3 in infant & neonate., (adult level
achieved at 2 years of age)
In infancy spinal; anesthesia given at L4-L5. Level
In adult spinal anaesthesia given at L3-L4 OR L4rL5
space, (even at L2~L3)
In. adult usually spinal anesthesia given at l3-l4 level
Remember structures encountered during spinal
anesthesia
1-skin, 2-subcutaneous tissue, 3-supraspinous
ligament, 4-lnterspinous ligament, 5-ltgament
flavum, 6-dura, 7-arachnoid.
58. A 50-yrs-old male has a severe vomiting and
retching spell with 'sharp substernal pain. He comes to
you 4 h later and has a chest film in which the left
descending aorta is outlined by air density. Optimum
strategy for care would be:
1. Immediate thoracotomy
2. Serial ECGs and CPKs to rule out MI
3. Left chest tube and spit fistula
4. Esophagogastroscopy to establish diagnosis
Ans. 1
The presence of air in the mediastinum after an episode of
vomiting and retching is virtually pathognomonic of
spontaneous rupture of the esophagus (Boerhaave
syndrome). The evidence is overwhelming that without
prompt surgical exploration of the mediastinum by left
thoracotomy, the patient has little chance for a short-term
outcome of low morbidity. The aspiration of highly acidic
gastric contents into the mediastinum creates havoc in the
tissues exposed to it. The surgical procedure must include
extensive opening of the mediastinal pleura and removal
of any particulate debris that might have been aspirated
into the thorax from the stomach. Closure of the
esophageal laceration with reinforcement by a pleural flap
and secure chest tube drainage of the pleural space are
mandatory.
59. A 27-yrs-old woman seeks your advice regarding
pain and numbness in the right arm and hand .. She
reports that it is exacerbated by raising her arm over
her head. A provisional diagnosis is made. Which
statement is true of this conditions?
1. It is associated with cervical spine disk disease
2. It is reliably diagnosed by positional obliteration of the
radial pulse
3. If conservative measures fail, it is best treated by
surgical decompression of the brachial plexus
4. It most commonly affects the median nerve
13
Ans. 3
The thoracic outlet syndrome designates a symptom
complex whose precise cause is unknown. It is felt to result
from compression of the brachial plexus or subclavian
vessels, or both, in the anatomic space bounded by the first
rib, the clavicle, and the scalene muscles. Since objective
determinants of disease may be lacking or imprecise, the
diagnosis often is established by resectional surgery.
Carpal tunnel syndrome (compression of the median nerve
as it passes through the carpal tunnel of the wrist) and
cervical disk disease are the two entities most commonly
confused with the thoracic out let syndrome, whose
symptoms and signs include pain, paresthesias, edema,
venous congestion, and digital vasospastic changes.
Positional dampening or obliteration of the radial pulse is
an unreliable finding since it is present in up to 70% of the
normal population. Neurologic abnormalities may be
documented by nerve conduction studies. Angiographic
studies are often negative. Conservative management,
which generally should precede surgery, consists of an
exercise program to strengthen shoulder girdle muscles
and decrease shoulder droop. Operative treatment
includes division of the scalenus anticus and medius
muscles, first rib resection, cervical rib resection, or a
combination of all three.
60. A 4-yrs-old boy is brought to the physician by his
parents for episodes of waking in the middle of the
night screaming. The parents state that when they get
to the boy's room during one of these episodes, they
find him in his bed, thrashing wildly, his eyes wide
open. He pushes them away when they try to comfort
him. After 2 min, the boy suddenly falls asleep, and the
next day he has no memory of the episode. Which of
the following medication is used to treat this disorder?
1. Haloperidol
2. Diazepam
3. Methylphenidate
4. Amitriptyline
Ans. 2
The child in the question is experiencing episodes of sleep
terror disorder, a dyssomnia characterized by sudden
partial arousal accompanied by piercing screams, motor
agitation, disorientation, arid autonomic arousal. The
episodes take place during the transition from deep sleep
to REM sleep. Children do not report nightmares (which
would be associated with REM sleep) and do not have any
memory of the episodes the next day Sleep terrors occur in
3% of children and I % of adults. Although specific
treatment for this disorder is seldom required, in rare
cases it is necessary. Diazepam in small doses at bedtime
improves the condition and sometimes completely
eliminates the attacks.
61. A 37-yrs-old alcoholic is brought to the
emergency room after he was found unconscious
in the street. He is hospitalized for dehydration
and pneumonia. While being treated, he becomes
acutely confused and agitated He cannot move
his eyes upward or to the rig , and he is ataxic.
Which of the following diagnosis is most likely?
1. Alcohol intoxication
2. Korsakoff's syndrome
3. Alcohol delirium
4. Wernicke's encephalopathy
Ans. 4
Wernicke's encephalopathy occurs in nutritionally
deficient alcoholics and is due to thiamine deficiency and
consequent damage of the thiamine- dependent brain
structures, including the mammillary bodies and the
dorsomedial nucleus of the thalamus. It presents with
mental confusion, ataxia, and sixth nerve paralysis.
Wernicke's encephalopathy is a medical emergency and
can rapidly resolve with immediate supplementation of
thiamine.
62. Hill - Sach's lesion seen in:
1. Anterior dislocation of hip
2. Posterior dislocation of hip
3. Recurrent dislocation of shoulder
4. Posterior dislocation of shoulder
Ans: (3)
Hill Sach's lesion and Bankart lesion causes recurrent
dislocation of shoulder
In previous year they asked about the Luxation Inferior
dislocation.
Most common Type of Shoulder dislocation anterior
dislocation of shoulder (sub-coracoid type) dislocation.
Surgeries for Recurrent dislocation of shoulder:
Bankart s operation
Puti platt's operation
Bristow's operation.
63. A schizophrenic patient has no interest in social
contacts or vocational rehabilitation. His affect is flat,
and he speaks very little and spends most of his day
sitting in front of the TV, unwashed and unshaven. He
has some chronic, delusions of persecution, but these
do not impact his functioning as much as the previous
symptom. Which of the following anti psychotics.
Would-tie most appropriate to use in treating this
patient?
1. Molindone
2. Haloperidol decanoate
3. Chlorpromazine
4. Olanzapine
Ans. 4
The schizophrenic patient in the question manifests a
prevalence of negative symptoms (flat affect, abulia, lack of
motivation). Two antipsychotic medications have been
proved to be effective for negative symptoms: clozapine
and olanzapine. However, due to clozapine's high risk for
agranulocytosis, its use is limited to refractory cases of
14
schizophrenia, severe tardive dyskinesia, and psychotic
symptoms in patients with Parkinson's disease.
64. A 51-year-old man has noted right hip pain for the
past 3 months. On physical examination he has
diminished range of motion of the right hip. A
radiograph reveals a 10 x 13 cm mass involving the
right ischium of the pelvis. The mass has irregular
borders and there are extensive areas of bony
destruction along with some scattered calcifications.
The lesion is resected, and grossly the mass has a
bluish-white cut surface. Which of the following
attributes is most likely to describe this mass?
1. The most frequent primary tumor of bone
2. Usually seen in distal skeletal bones
3. More common in females
4. Sometimes seen to arise in benign cartilagenous
tumors
Ans. 4
CORRECT 4. Though probably a sporadic occurrence in the
case desccribed here, chondrosarcomas can occur in
association with osteochondromatosis.
Incorrect 1. Osteosarcoma is the most frequent primary
malignancy of bone, not chondrosarcoma.
Incorrect 2. Distal cartilagenous tumors are more likely to
be benign, whereas those in a central location are virtually
always malignant.
Incorrect 3. Primary malignancies of bone, including
chondrosarcoma, are more common in males.
65. M/C used in Brachytheraphy of Carcinoma cervix:
1. Radium-226
2. Cobalt-60
3. Gold-198
4. Caesiom-137
Ans: (4)
Brachytherapy: Type of radiation in which radioactive
sources are placed in dose proximity to or directly into
tumors.
Interstial RT Needles Placed into Prostate/penis/other
soft tissue.)
Intracavitary
eg. In urethra (m/c used csl37) M/C used source in
Brachytherapy - Irl 90. C.S.I. REMEMBER, some
commonly asked half life of ISOTOPES
Radium 2261620 years
Caesium- 13730 years
Cobalt 60 ----- 5.3 years
Iridium 19274.4years
Iodine 125 ---- 60 days
Phosphorus3214.3 days
Gold 1982.7 days
66. A 38-yrs-old woman with bipolar disorder has
been stable on lithium for the past 2 years. She comes
to her psychiatrist's office in tears after a 2week
history of a depressed mood, poor concentration, loss
of appetite, and passive suicidal ideation. Which of the
following steps should the psychiatrist take next?
1. Start the patient on a second mood stabilizer
2. Start the patient on a long-acting benzodiazepine
3. Stop the lithium and start an antidepressant
4. Start an antidepressant and continue the lithium

Ans. 4
Since lithium and other mood stabilizers are more effective
in the prevention of manic episodes than in the prevention
of depression, antidepressants are used as an adjunctive
treatment when depressive episodes develop during
maintenance with a mood stabilizer. Since the incidence of
antidepressant-induced mania is high (up to 30%), and
since antidepressant treatment may cause rapid cycling,
the antidepressant should be tapered and discontinued as
soon as the depressive symptoms remit. Among the
antidepressants in common use, buproprion is considered
to carry a slightly lower risk of triggering mania.

67. Which of the following statements about

obsessive-compulsive disorder is correct?
1. It usually has an onset in middle age
2. It has a lifetime prevalence of 2.5%
3. It is usually caused by traumatic events 1. Ulcerative colitis
4. It is not responsive to pharmacological intervention 2. Carcinoma colon
3. Crohn's disease
Ans. 2 4. Whipple's disease
Obsessive-compulsive disorder usually has its onset from
late childhood to early adulthood and has a lifetime Ans, 1
prevalence of about 2.5%. Stress is usually associated with Pipestem colon is seen in ulcerative colitis
worsening of symptoms, but traumatic events do not cause String sign of Kantor is seen in Crohn 's disease.
this disorder. While a minority of patients do have periods
of complete remission, about one-third have a fluctuating 69. A 40-year-old man is brought by his friends to you.
course and up to 60% have a constant or progressive Apparently, he has ingested some unknown
course. Many patients are markedly improved by medication. Patient is disoriented. His temperature is
pharmacological intervention. The most commonly used 103F, BP 120/85, pulse 100/min, and respirations
agents are serotonin reuptake inhibitors such as fluoxetine 221min. The skin is flushed and dry. Has dilated pupils
and sertraline, although the tricyclic clomipramine is also and muscle twitching. ECG reveals prolonged QRS
used. complexes. Hepatic transaminases are normal, and
ABG shows a normal pH. These findings are most likely
68. Below X-ray is seen in: due to intoxication by which of the following
substances?
1. Acetaminophen
2. Alcohol
3. Benzodiazepines
4. Tricyclic antidepressants

Ans. 4
This patient's clinical picture is consistent with
intoxication with tricyclic antidepressants such as
amitriptyline and imipramine. Toxic effects 'are mediated
by peripheral anticholinergic activity and "quinidine-like"
action. The anticholinergic effects include mydriasis,
tachycardia, impaired sweating with flushed skin. dry
mouth, constipation, and muscle twitching. Quinidine-like
effects (due to block of sodium channels in. the heart)
result in cardiac arrhythmias, especially ventricular
15
tachyarrhythrnias, In this setting, prolongation of the QRS
complex is particularly important in the diagnosis. QRS
width is, in fact. an even more faithful parameter of drug
toxicity than serum drug levels. In severe intoxication,
patients will develop seizures, severe hypotension, and
coma.
70. A 50-year-old man is brought to the emergency
department by ambulance. His respirations are
shallow and infrequent, his pupils are constricted, and
he is stuporous. He was noted to have suffered a
grandmal seizure in the ambulance. Which of the
following drugs is this man likely to have overdosed
on?
1. Cocaine
2. LSD
3. Meperidine
4. PCP
Ans. 3
Severe opiate intoxication is associated with respiratory
depression, stupor or coma, and sometimes pulmonary
edema. Less severe intoxication is associated with slurred
speech; drowsiness, and impaired memory or attention.
Early on, the pupils are constricted, but they dilate if the
patient becomes 'anoxic due to the respiratory depression.
BP is typically. Meperidine intoxication in a chronic user is
often complicated by delirium or seizures due to the
accumulation of nor meperidine, a toxic metabolite with
cerebral irritant properties.
71. Filament in X-ray made of:
1. Tungsten filament
2. Chromium
3. Gallium
4. Selenium
Ans: (1)
Please remember: Target is not Tungsten in
mammography, its made up off molybdenum.
72. A 25-year-old man with major depression '
discusses the potential benefits and side effects of
various antidepressants with his psychiatrist. He
clearly indicates that he does not want a medication
that could decrease his libido or interfere' with his
ability to obtain and maintain an erection. Which of
the listed antidepressants would be appropriate for
this patient?
1. Bupropion
2. Clomipramine
3. Amitriptyline
4. Sertraline
Ans. 1
Tricyclic antidepressants such as clomipramine and
amitriptyline and SSRIs such as paroxetine and sertraline,
as well as MAOIs, can cause erectile dysfunction, delayed
16
ejaculation, anorgasmia, and decreased libido. Buproppion,
mirtazapine, trazodone, and nefazodone, in contrast, do
not affect sexual functions in a negative way Trazodone
and nefazodone, however, have been implicated in cases of
priapism and should not therefore be used as first-line
medications in male patients.
73. DNA sequencing by the Sanger method take:
advantage of which property of DNA synthesis to
generate a sequencing ladder?
1. Addition of nucleotides requires a free 01-I group on
the 3' end of the DNA strand
2. DNA has a free 5' phosphoryl group
3. DNA polymerase has proofreading capabilities
4. Nucleotides are linked by phosphodiester bonds
The answer is 1.
The Sanger method of DNA sequencing is also known as
chain termination sequencing. In this method, DNA strands
are synthesized in the presence of a low concentration of
dideoxynucleosides (ddNTPs) in addition to
deoxynucleotides (dNTPs). Incorporation of a dNTP allows
synthesis to continue as there is a free 3-OH group for
addition of the next nucleotide. Incorporation of a ddNTP
terminates synthesis of the DNA strand as there is no free
3OH group for addition of the next nucleotide.
In Sanger sequencing, four reactions (A, C, T, and G) are
run, each containing the appropriate ddNTP. The mixture
of DNA strands generated in each reaction includes
strands that are terminated at each given nucleotide (e.g.,
the A reaction contains DNA strands terminated at each A).
The four reactions are run adjacent to one another on an
acrylamide gel to separate the strands by size. The
sequence of the DNA is determined by reading the order of
the terminated chains going up the gel.
74. Investigation of choice in a person brought with
traumatic paraplegia is:
1. MRI
2. CT
3. Myelography
4. USG
Ans: (1)
All spinal imaging is done by MRI
MRI is safe in pregnancy Unit of MRI
is TESLA.
75. Which of the following characterizes Q fever?
1. Has an incubation period of four to six weeks
2. is an acute febrile illness caused by Coxiella Burnetii
3. Is an illness confined to the upper respiratory tract
4. Is most commonly found in tropical region
Ans. 2
Q fever is an acute, flulike illness caused by C. burnetii. It is
the one rickettsial disease not transmitted by the bite of a
tick. C. burnetii is found in high concentrations in the
urine, feces, and placental tissue/amniotic fluid of cattle,
goats, and sheep. Transmission to humans is by aerosol
inhalation of those specimens.
76. Which one of the following organism normally
inhabits the healthy human oral cavity?
1. M. fermentans
2. M. hominis
3. M. pneumoniae
4. M. orale
Ans. 4
Members of the mycoplasma group that are pathogenic for
humans include M. pneumoniae and U. urealyticum. M.
pneumoniae is best known as the causative agent of
primary atypical pneumonia (PAP), which may be
confused clinically with influenza or legionellosis. It also is
associated with arthritis, pericarditis, aseptic meningitis,
and the Guillain-Barn5 syndrome. M. pneumoniae can be
cultivated on special media and identified by
immunofluorescence staining and "fried egg" colonies on
agar.
U. urealyticum (once called tiny, or T, strain) has been
implicated in cases of nongonococcal urethritis. As the
name implies, this organism is able to split urea, a fact of
diagnostic significance. U. urealyticum is part of the
normal flora of the genitourinary tract, particularly in
women.
Both M. orale and Mycoplasma salivarium are inhabitants
of the normal human oral cavity. These species are
commensals and do not play a role in disease.
The only other species of Mycoplasma associated with
human disease is M. hominis. A normal inhabitant of the
genital tract of women, this organ ism has been
demonstrated to produce an acute respiratory illness that
is associated with sore throat and tonsillar exudate, but
not with fever.
M. fermentans is an animal isolate.
77. Which one of the following is characteristic of
microfilaria of W. bancrofti?
1. Cephalic space twice as long as broad
2. Excretory pore prominent
3. Nuclear column smudged
4. Caudal end uniformly tapering to a delicate point, and
no terminal nuclei present
Ans. 4
The features of microfilaria of W. bancrofti are:
General appearance: Graceful, sweeping curves.
Free cephalic space: As long as broad.
Excretory pore: Not prominent:
Caudal end: Uniformly tapering to a delicate point and no
terminal nuclei present.
5. Nuclear column: Nuclei discrete; Important points
1. Microfilaria of W. bancrofti and B. malayi in India
display a nocturnal periodicity. Maximum density of Mf in
blood is reported between 10 pm and 2 am.
2. Man is the definitive host and mosquito the intermediate
host of Bancroftian and Brugian filariasis.
17
Third stage larva in mosquito is infective form.
Adult worm may survive for 15 years or more.
5. Duration of mosquito cycle (extrinsic incubation period)
is between 10 and 14 days.
6. Main vectors in India are: C. quinquefasciatus (C.
fatigans) for Bancroftian filariasis and Mansonia
mosquitoes for Brugian filariasis.
7. Prepatent period: It is the time interval between
inoculation of infective larvae and the first appearance of
detectable Mf.
8. Clinical incubation period: Time interval from invasion
of infective larvae to the development of clinical
manifestations.
78. H. capsulatum, is found in soil heavily
contaminated with bird droppings. Which of the
following statements best describes the presence of
the organism in tissue biopsies?
1. Arthrospores
2. Oval budding yeast inside macrophages
3. Single-cell yeast with pseudohyphae
4. Spherules containing endoscopores
Ans. 2
H. capsulatum is a dimorphic fungus that forms two types
of spores: tuberculate macroconidia and microconidia.
Inhalation of the microconidia transmits infection. Inhaled
spores (microconidia) are engulfed by macrophages and
develop into yeast forms. Most infections remain
asymptomatic; small granulomatous foci heal by
calcification. However, pneumonia can Occur. The
heterophile anti body test is useful for early diagnosis of
infectious mononucleosis.
79. The diagnostic characteristics of Plasmodium
falciparum are best described by which one of the
following statement?
1. An important diagnostic feature is the irregular
appearance of the infected red blood cell
2. A period of 72 Hour is required for development of the
mature schizont, which resembles a rosette with only
8 to 10 oval merozites
3. Except in infection with very high parasitemia, only
ring forms of early trophozoites and the gametocytes
are seen in the peripheral smear
4. Schuffner stippling is routinely seen in red blood cells
that harbor parasites
Ans. 3
P. falciparum infection is distinguished by the appearance
of ring forms of early trophozoites and gametocytes, both
of which can be found in the peripheral blood. The size of
the RBC is usually normal. Double dots in the rings are
common.
80. Alopecia, Hyper pigmentation, Hypogonadism
characteristic for deficiency of
1. Zinc
2. Magnesium
3. Selenium
4. Copper
Ans: (1)
The essential feature of Zinc deficiency.
1. A distinctive rash most often around the eyes,
nose, mouth, anus and distal parts called
Acrodermatitis Enteropathica.
2. Growth retardation in children.
3. Impaired wound healing
4. Hypogonadism with diminished reproductive
capacity.
5. Anorexia often accompanied by diarrhoea
6. Depressed mental function.
Other important disease
Selenium deficiency causes Keshan disease.
Copper deficiency causes Menke's disease.
81. Survival of allografts is increased by choosing
donors with few MHC mismatches with recipients and
by use of immunosuppression in recipients. Which one
of the following procedure might be useful measure of
immunosuppression?
1. Administration of corticosteroids to recipient
2. Administration of immunoglubin to recipient
3. Destruction of donor B cells
4. Destruction of donor T cells
Ans. 1
Allograft rejection is primarily a T cell response to foreign
tissue. The corticosteroids reduce inflammatory response
and are generally administered by cytotoxic drugs, such as
cyclosporine. Lymphoid irradiation is usually done so that
the bone mar row is shielded. This removes lymphocytes
from lymph nodes and spleen while allowing the patient to
have the capacity to regenerate new T and B cells.
Likewise, antilymphocyte globulin will destroy the
recipient's lymphocytes, especially T cells. Destruction of
donor B cells and T cells would not play a role in the
immunosuppression of the graft recipient. In graft crises,
monoclonal antibody to CD3 is sometimes given. This
targets mature T lymphocytes for destruction.
82. A laboratory analysis report of a specific fraction of
a patient's lymphocytes the following:
HLA, Band C+,PHA+, CD3-, CD16+, CD11a/ CD18+,
CD56+, and in vitro blastogenesis with IL12 What are
the lymphocytes this set describes?
1. B lymphocytes
2. Cytotoxic T lymphocytes
3. Natural killer cells
4. T helper 1 subset
Ans. 3
NK cells do not express a cell surface TCRlCD3 complex
and are CD4-. About half of human NK cells are CD8+. Also,
most NK cells express an Fe IgG receptor, known as CDI6,
and CD56, a neural cell adhesion molecule variant. NK cells
18
are generally CD16+, CD56+, and CD3-, which contrasts
them with I cells which are CD3+, CDl6-, and CD56
83. Isomorphism not seen in:
1. Lichen planus
2. Warts
3. Psoriasis
4. Vitiligo
Ans: (4)
Isomorphism or Koebner phenomenon-It means linear
lesions produced by scratching a primary lesion which
results in new lesions developing along the line of the
scratch. Eg: Lichen planus, warts and psoriasis. But
Koebner phenomenon is characteristic for Lichen
planus.
84. The sodium gradient across the nerve cell
membrane IS:
1. A result of the Donnan equilibrium
2. Significantly changed during an action potential
3. Used as a source of energy for the transport of other
ions
4. An important determinant of the resting membrane
potential
Ans. 3
The sodium- potassium pump uses the energy contained in
ATP to maintain the sodium gradient across the
membrane. The sodium gradient, in turn, is used to
transport other substances across the membrane. For
example, the NaCa exchanger uses the energy in the
sodium gradient to help maintain the low intracellular
calcium required for normal cell function. Although
sodium enters the cell during an action potential, the
quantity of sodium is so small that no significant change in
intracellular sodium concentration occurs. Because the
sodium transference is so low, the sodium equilibrium
potential is not an important determinant of' the resting
membrane potential.
85. Decrease number of melanocyte is seen in:
1. Albinism
2. Piebaldism
3. Ichthyosis
4. Chemical leucoderma
Ans: (2)
Piebaldism is a Autosomal dominant disease characterized
by patches of skin that lack melanin as a result of defect in
migration of melanoblast from neural crest to skin.
Skin biopsy: Hypo melanotic area-few to no melanocytes.
Vitiligo: is an acquired disease and similar patch of loss of
melanin, but the loss develops after birth and progressive.
Albinism: Congenital inability to synthesize melanin.
86. Not a cutaneous manifestation of TB:
1. Lupus pernio
2. Lupus vulgaris
3. Erythema nodosum
4. Scrofuloderma
Ans: (1)
Lupus pernio is a skin manifestation of Sarcoidosis.
Sarcoidosis does not involve kidney.
Sarcoidosis mimics like Berylliosis.
87. An ECG obtained from a 57-yrs-old male during a
routine physical examination reveals atrial
fibrillation. Which of the following is most likely to
accompany this condition?
1. An increased venous 'a' wave
2. An increased left atrial pressure
3. A decreased heart rate
4. An increased stroke volume
Ans. 2
Atrial fibrillation is an arrhythmia in which the electrical
activity of the atrium becomes disorganized and therefore
unable to produce a coordinated atrial contraction. The
absence of an atrial pulse reduces the emptying of the atria
during diastole and results in an enlarged left atrium and
increased left atrial pressure. The venous A wave
represents atrial contraction and disappears due to the
absence of an atrial beat. Decreased filling of the heart
results in a decrease in stroke volume. Heart rate increases
because the continuous electrical activity of the atria
initiates a high rate of ventricular activity Systemic blood
pressure typically falls because of inadequate filling of the
ventricles and the resulting decrease in stroke volume.
88. Stroke volume can be decreased by which of the
following?
1. Increasing ventricular contractility
2. Increasing heart rate
3. Decreasing total peripheral resistance
4. Decreasing systemic blood pressure
Ans. 2
Stroke volume is determined by preload, afterload, and
contractility Increasing heart rate decreases the time for
filling during diastole and may decrease preload and
therefore stroke volume. Increasing preload by increasing
central venous pressure will increase stroke volume.
Similarly, decreasing afterload by decreasing total
peripheral resistance or systemic blood pres sure will
cause an increase in stroke volume, Increasing
contractility will also increase stroke volume.
89. Which one of the following is not a polygenic
disorder?
1. Down's syndrome
2. Diabetes mellitus
3. Coronary heart disease
4. Congenital heart disease
Ans. 1
19
Down syndrome or mongolism is caused by trisomy of
chromosome 21.
- It is characterized by short stature and small rounded
head, narrow, tilted eye slits, malformed ears, short broad
hands, lax limbs, mental retardation, cardiac defects and
atresia of alimentary tract.
- The frequency of mongolism increases with rising
maternal age but is unaffected by the age of the father.
Polygenic or multifactorial disorders are essential
hypertension, schizophrenia, mental retardation, duodenat
ulcer, ischaemic heart disease of early onset, diabetes
mellitus, congenital heart malformation, familial cancer
syndromes including familial polyposis coli, familial non
polyposis colon cancer and some thyroid thncers. Also in
cancer of colon and breast, there is a major genetic
component but it is difficult to distinguish familial from
non familial cases.
The mode of inheritance of multifactorial disorders, is
complex because environmental factors are also involved.
The relative contributions of genetic predisposition and
environmental factors to the aetiology will vary greatly
from patient to patient.
90. Which of the following tend to show marked and
homogeneous enhancement on Gd-DTPA enhanced
MRI?
1. Meningiomas and acoustic neuromas
2. Oligodendrogliomas and Metastases
3. Meningiomas and low grade gliomas
4. Glioblastoma multiformies and acoustic neuromas
Ans. (1)
Meningiomas and acoustic neuromas tend to show marked
and homogeneous enhancement 0." Gd-DTPA-enhanced
MRI Ring-shaped contrast enhancement occurs in most
glioblastoma8, whereas low-grade gliomas may show lack
of changes on postcontrast images or only patchy
enhancement.
Depending on tumor size, metastases present as small
homogeneously enhancing lesions or as ring-shaped
structures secondary to central necrosis, which adds to the
hallmark of metastatic tumors (i.e., multiplicity of lesions).
91. Which of the following test is positive in Anterior
dislocation of shoulder?
1. Thomas test
2. Barlow's test
3. McMurry's test
4. Duga's test
Ans. 4
The following signs, associated with anterior dislocation
of shoulder.
a. Duga's test
b. Hamilton ruler test
c. Caliway's test.
92. A neonate with respiratory distress and the
following chest X ray most likely has:

1. Cystic fibrosis
2. CLE
3. CCAM
4. Pneumonia
Ans. 2
93. Use of condom prevents which of the following
diseases?
1. Carcinoma cervix
2. Carcinoma vulva
3. Herpes simplex genitalis
4. All of the above
Ans. 4
The incidence of CA cervix is low amongst woman whose
partners use condom because of prevention of
transmission of viral infection (HPV) causing CA cervix.
Similarly it can also reduce the risk of CA vulva because it
is common in women suffering from STD. Herpes genitalis
is a DNA virus. It is transmitted sexually and is an
aetiological agent of CA cervix. The incubation period is 3-
6 days. Vesicles appear on erythematous base on vulva,
vagina and rarely cervix. These vesicles soon rupture
leaving multiple shallow ulcers which are painful after
bacterial infections. Treatment is with acyclovir. Besides
CA cervix it can also causes CA vulva and condom can
prevent the transmission. Female latex condoms are most
useful in prevention of CA vulva.
94. The visual disturbance of methylalcohol poisoning
include all of the following except:
1. Pin point pupils
2. Photophobia and blurred vision
3. Concentric diminution of visual fields for colour and
form
4. Sudden failure of vision
Ans. 1
Clinical Features of Methanol Poisoning
- Headache, dizziness, Nausea and vomiting
- Pain in abdomen, Muscular weakness, Acidosis
Blurred vision, diminution of visual field temporary
blindness or permanent blind in severe case ofpoisoning.
Intestinal contraction is diagnostic of methanol poisoning.
Poisons producing constriction of pupils are
following:
- Opium, Physostigmine, Phenol, Chloralhydrate
- Organophosphorus compound
20
Poison producing dilatation of pupils - Dhatura, Cyanides
Alternative contraction and dilatation &f pupils are found
in early stage of barbiturate poisoning.
95. Lumbar hemivertebra results due to the
abnormal development of:
1. Dorsal sclerotome.
2. Intermediate cell mass.
3. Notocord.
4. Ventral sclerotome.
Ans. (4)
The embryonic mesoderm on either side of the notochord
segments into paired somites, which differentiate into
sclerotome. myotome .. and dermatome portions. The
human vertebral column develops by endochondral bone
formation from the paired sclerotome elements. The
vertebral bodies are formed by fusion of a more compact
caudal portion of each sclerotome with the less dense
cranial portion of the sclerotome below, and dorsal
migration of sclerotome tissue will give rise to the paired
neural arches. At birth, ossification centers are present for
the centrum of the vertebral body and for each half of the
neural arches, which have a cartilaginous union to the
centrum at the neurocentral synchondroses.
Segmentation anomalies like with hemivertebrae, butterfly
vertebrae, and block vertebrae occur due to abnormal
development of Ventral sclerotome.
96. Which one of the following statement regarding
the female contraceptive "Today" is true?
1. It is polyurethane foam saturated with 9nonoxynol
2. It is an oral pill containing norethisterine acetate
1.0mg and ethinyl oestradiol 0.03 mg
3. It is an oral pill containing D-norgesterel 0.50 mg and
ethinyl oestradiol 0.3 mg
4. It is made of "gossypol" a derivative obtained from
cotton seed oil
Ans. 1
Today is a polyurethane foam that contains the
spermicidal agent 9-nonoxynol.
97. Quality control over drugs manufactured in India is
the responsibility of:
1. Pharmaceutical Council of India
2. Central drugs laboratory
3. Indian Medical Council
4. Drug Technical Advisory Board
Ans. 1
Central drug laboratory analyses imported and
manufactured drugs to know their constituents, purity and
potency.
Drugs technical advisory Board advise the central and
the state government on different technical matters
related to the administration of the act.
Pharmaceutical council of India has control and regulation Intent
regarding quality of drugs .
Drugs and cosmetics rule of 1945 regulates the import, 7-12 years Responsibility Sec. 83 IPC Guilty of
manufacture distribution and sale of drugs in India. offence
< 12 years Criminal Parents given
98. On MRI the differential diagnosis of spinal cord Responsibility 89 IPC consent for
edema is: Consent noninvasive
1. Mylodysplasia procedure
2. Myelomalacia
3. Myelochisis
4. Cord tumors 101. In a case of death due to burns, which of the
following statement is correct?
Ans. (2) 1. Red line of demarcation around the vesicle is
Both cord edema and myelomalacia appear as always present
On T1 Ill-defined hypointense area 2. Red line of demarcation around the vesicle is always
On T2 Hyperintense area absent
Cord Edema Myelomalacia I Cord 3. Red line of demarcation disappears soon after death
atrophy 4. Red line of demarcation, mayor may not form
Etiology Reflects In end stage of cord
focal trauma and result Ans. 1
accumulation release of vasoactive
of intracellular & substances & cellular
interstitial fluid in enzyme Antemortem Post mortem
response of
trauma. 1. Line of Present Absent
ischemia and redness
to injury 2. Vesicles Contain a Contain air
MRI Ill-defined Poorly marginated albuminous
T1WI hypointense area hypointense area fluid
T2WI Focus of Hyperintense cord
hyperintensity parenchyma
3. Infection Pus and Nil
Sloughing
99. Autoimmune haemolytic anemia is a feature of? 4.Healing Granulation Nil
1. ALL
2. CML
3. Burkett's Lymphoma 5. Carboxy Present Absent
4. Lymphoma Hb blood

Ans. 4
Causes of Autoimmune Hemolytic Anemias 6.Enzymes Increase in No such
Idiopathic (50%) enzymes increase
Drugs - Methyl dopa;
CLL, Lymphomas
M. Pneumoniae infection. 102. A 6 years old boy presented with Complex
IMN, SLE and other connective tissue disorders. seizures per day in spite of adequate 4 drug
antiepileptic regime. He had history of repeated
100. Nothing is an offence which is done by a child high-grade fever in childhood. MRI for epilepsy
under seven years of age' is included under which of protocol revealed normal brain scan. Which of the
the following section: following will not be helpful for functional imaging
1. Section 82 IPC of brain?
2. Section 83 IPC 1. MDCT
3. Section 84 IPC 2. SPECT imaging
4. Section 85 IPC 3. Interictal 18F-FDG PET
4. Video EEG with Ictal 99mTc- HMPAO study of brain
Ans. 1
Medicolegal importance of age Ans. (1)
Age Medicolegal IPC Ex planation Brain perfusion study using perfusion agents like Tc-99m
HMPAO, i.e., Tc-9W6HMPAO brain SPECT is indicated in
<7 year Criminal Sec.82 IPC No criminal
21
acute cerebral infarct imaging before evidence of CT/MRI
pathology, when positive findings are seen with 1 hour of
event. Brain metabolic rate and functional activity study by
using 18F FDG PET is indicated in focal epilepsy prior to
seizure.
MDCT is not useful for functional studies of brain.
103. Digoxin toxicity may result from the concurrent
administration of digoxin with all of the following
drugs EXCEPT
1. Quinidine
2. Hydrochlorothiazide
3. Triamterene
4. Furosemide
Ans. 3
Triamterene is a potassium-sparing diuretic that may
protect against diuretic-induced digoxin toxicity. Digoxin
toxicity may be caused by drugs that increase serum
digoxin levels or increase the binding of digoxin to its
receptor, the sodium-potassium adenosine tn phosphatase
(ATPase). Quinidine decreases digoxin volume of
distribution and clearance. Verapamil also decreases the
clearance of digoxin. Both drugs may
thereby increase serum digoxin levels and precipitate
digoxin toxicity. Diuretics (e.g., hydrochlorothiazide,
furosemide) may cause hypokalemia and
hypomagnesemia, both of which may predispose to cardiac
arrhythmias. Furthermore, hypokalemia increases di-goxin
binding to sodium-potassium ATPase.
104. All of the following statement about a normal
subject in the erect position are true EXCEPT
1. Alveoli at the apex of the lung are less compliant that
those at the base
2. Airway resistance is greater at the apex than at the
base
3. More gas exchange occurs at the base of the lungs than
at the apex
4. The ventilation/ perfusion ratio (VA/Qc) is lowest at
the base of the lung
Ans. 2
When the thorax is in the erect Position, the pressure
generated by the right ventricle is not sufficient to perfuse
apical alveoli to the same extent as it perfuses alveoli at the
base of the lungs. Approximately IS times more blood
flows through the capillaries at the base than at the apex.
In addition, while erect, the more negative intrapleural
pressure at the apex causes the overstretched alveoli in
this region to resist further stretch more strongly; i.e., the
compliance of the alveoli is less at the apex than at the
base. Consequently, about four times more gas goes to the
base than to the apex. Most of the gas exchange in the
lungs takes place at the base when the thorax is erect
because the base is the place where most of the blood and
gas are located. However, there is too much blood for the
amount of air at the base; that is, the base has a low
ventilation/perfusion ratio (VAIQe). Conversely, there is
22
too much air for the amount of blood at the apex; that is,
the apex has a high VA/QC.
The more negative intrapleural pressure at the apex
distends airways causing the resistance to flow to be lower
at the apex than at the base.
105. Intramembranous ossification is the source of ?
1. A Flat bone
2. B. Long bone
3. C. Cancellous bone
4. D. Bone of the epiphysis
Ans. 1
Intramembranous ossification is the development of bone
from mesenchymal condensation. Mesenchyme cells give
rise to osteoblasts, which lay down bone matrix and
eventually form bone spicules. When the osteoblasts
become enclosed, they are called osteocytes. The frontal,
parietal, squamous portion of the temporal, and parts of
the occipital bone are derived from intramembranous
ossification.
Long bones develop from a cartilage model, which is called
endochondral ossification Growth in length occurs by
division of cells in the epiphyseal plate. Cancellous bone is
spongy, or trabecular bone, which can result after either
intramembranous or endochondral ossification.
106. Which substance, if used for a long time is
associated with memory loss?
1. Marijuana
2. Alcohol
3. Cocaine
4. LSD
Ans. 2
Alcohol amnestic disorder (Korsakoff syndrome) is the
result of long-term alcohol abuse.
107. The oculomotor nerve passes between which pair
artery?
1. A Superior cerebellar artery and posterior cerebral
artery
2. Posterior inferior cerebellar artery and anterior-
cerebellar artery
3. Posterior cerebellar artery and middle cerebral Artery
4. Posterior cerebral communicating artery
Ans. 1
The oculomotor nerve emerges from the midbrain and
passes between the two cerebral peduncles. The nerve
then passes between the superior cerebellar artery and the
posterior cerebral artery before entering the dura of the
lateral wall of the cavernous sinus Because of the close
relationship between the oculomotor nerve and, the
superior cerebellar, posterior cerebral, and basilar
arteries: an aneurysm of any of these three arteries can
compress the oculomotor nerve.
108. Uncontrolled flailing of an arm is a symptom of?
1. Amyotrophic lateral sclerosis innervate the infrahyoid strap muscles: sternohyoid,
2. Lower motor neuron syndrome sternothyroid, and omohyoid. The geniohyoid muscle is
3. Dysdiadochokinesias innervated by cervical nerve fibers that are carried with
4. Hemiballismus the hypoglossal nerve. The mylohyoid is innervated by a
branch of the mandibular division of the trigeminal nerve.
Ans. 4 The cricothyroid and cricoarytenoid muscles are intrinsic
Hemiballismus is associated with a lesion of the sub muscles of the larynx and are innervated by branches of
thalamic nucleus of the motor system. Lesions in this the vagus nerve.
nucleus produce uncontrolled flailing and involuntary
movement, especially of the upper extremity. Amyotrophic
lateral sclerosis, a disease of the lower motor neurons, 112. Which muscle has the phrenic nerve on its
produces weakness in skeletal muscles, which may anterior surface?
eventually lead to paralysis and muscle atrophy. 1. Sternocleidomastoid
Athetosis refers to slow writhing movements of the limbs. 2. Anterior digastric
This finding is characteristic of lesions in areas of the basal 3. Superior belly of the omohyoid
ganglia that are not subthalamic. 4. Anterior scalene

109. Which nerve is a branch of a root of Ans. 4

the brachial plexus? The phrenic nerve lies on the anterior surface of the
1. Suprascapular nerve anterior scalene muscle. The nerve is held tightly against
2. Dorsal scapular nerve the surface of the muscle by the deep cervical fascia The
3. Upper subscapular nerve roots of the brachial plexus and the subclavian artery pass
4. Lateral pectoral nerve posterior to the anterior scalene muscle and anterior to
the middle scalene muscle.
Ans. 2
The roots of the brachial plexus are the anterior rami of 113. A 58-year-old man has the sudden onset late one
spinal nerves Cs-T1. These five roots form the three trunks evening of severe pain in his left great toe. There is no
of the plexus. Each trunk divides into an anterior and a history of trauma. On examination there is edema with
posterior division. The divisions form the three cords of erythema and pain on movement of the left 1st
the brachial plexus. The dorsal scapular nerve is a branch metatarsophalangeal joint, but there is no overlying
of the C, root. The supra scapular nerve is a branch of the skin ulceration. A joint aspirate is performed and on
upper trunk. The upper subscapular nerve and the microscopic examination reveals numerous
thoracodorsal (middle subscapular) nerve are branches of neutrophils. Over the next 3 weeks, he has two more
the posterior cord. The lateral pectoral nerve is a branch of similar episodes. On physical examination between
the lateral cord. these attacks, there is minimal loss of joint mobility.
Which of the following laboratory test findings is most
110. In schizophrenia, hallucinations are to be? characteristic for his underlying disease process?
1. Visual 1. Hyperglycemia
2. Kinesthetic 2. Positive antinuclear antibody
3. Auditory 3. Hyperuricemia
4. Olfactory 4. Hypercalcemia

Ans. 3 CORRECT 3. Many patients with gout will have

In schizophrenia, the most common type of hallucination is
auditory. Other types of hallucinations, such as cenesthetic
(altered sensations of body organs), visual, olfactory, and
kinesthetic, can also occur.
111. Which muscle receives its nerve supply from a
direct branch of the ansa cervicalis ?
1. Mylohyoid
2. Geniohyoid
3. C Sternohyoid
4. Cricothyroid
Ans. 3
The ansa cervicalis is formed by nerve fibers from the
anterior rami C It gives rise to nerves that
hyperuricemia, but not all. The big toe is the most common
joint involved with gout. Acute gouty attacks are
associated with intense pain from acute inflammation.
Incorrect 1. Hyperglycemia is a feature of diabetes
mellitus, which is associated with peripheral vascular
disease that increases the risk for foot ulcerations and
osteomyelitis.
Incorrect 2. The arthralgias common to many autoimmune
diseases with a positive ANA, such as systemic lupus
erythematosus, are not usually associated with joint
swelling, redness, or deformity.
Incorrect 4. There can be bone luceny with
hyperparathyroidism, but the joints are not greatly
affected, nor is there swelling or redness.

23

114. Which of the following bone
disease/pathogenesis relationships is NOT CORRECT?
1. Osteogenesis imperfect: decreased mineralization of
bone
2. Osteopetrosis: osteoclast dysfunction
3. Achondroplasia: premature closure of the epiphyseal
plate of long bones
4. Postmenopausal osteoporosis: osteoclastic activity
predominates over osteoblastic activity
Ans. 1
Osteogenesis imperfecta, or brittle bone disease, is the
most common hereditary bone condition and, in most
cases, is an autosomal dominant disease. Resulting from
abnormal collagen synthesis, osteogenesis imperfecta
causes abnormalities in the skeleton (frequent pathologic
fractures), eyes (blue sclera from too little collagen), ears
(hearing deficits), joints (laxity), and teeth (dentin
deficiency causes blue-yellow discoloration)
115. Which is LEAST likely to characterize anxiety?
1. Syncope
2. Palpitations
3. GIT disturbances
4. Flight of ideas
Ans. 4
Anxiety is characterized by restlessness, dizziness,
palpitations, syncope, tingling in the extremities, tachy
cardia, tremor, gastrointestinal disturbances, as well as
urinary urgency and frequency. Flight of ideas (thoughts
following each other in quick succession) is characteristic
of mania.
116. Characteristics of smooth and cardiac muscle
include all of the following EXCEPT?
1. Gap junctions
2. Central nuclei
3. Branching fibers
4. Perinuclear organelles
Ans. 3
Cardiac muscle consists of long, branching fibers whereas
smooth muscle cells or fibers are unbranched. Cardiac
muscle is striated and resembles skeletal muscle in its
arrangement of contractile elements. Cardiac fibers that
are specialized to conduct impulses are called Purkinje
fibers. Central nuclei, one per cell, are common to smooth
and cardiac muscle. Skeletal muscle has multiple nuclei per
cell.
Gap junctions are a component of the cardiac muscle
intercalated disk, in addition to desmosomes and a fascia
adherens (zonula adherens) Gap junctions join smooth
muscle cells, allowing for a wavelike spread of contraction.
117. Which one of the following associations is NOT
CORRECT?'
24
1. A Rapid supination and pronation of the
hands- cerebellar function
2. Stereognosis -sensory cortex
3. Clasp knife reflex-upper motor neuron disease
4. Romberg's test-lower motor neuron disease
Ans. 4
Romberg's test primarily evaluates joint position, which is
a function of the dorsal columns, the patient is asked to
stand with the feet together and eyes closed. Loss of
balance with the eyes closed that is corrected by opening
the eyes indicates dorsal column disease (e.g., tabes
dorsalis). Loss of balance with the eyes open or closed
indicates a cerebellar problem, but that is not the primary
purpose of the test.
118. Avascular necrosis of bone is LEAST likely to be
associated with?
1. Osgood -Schlatter disease
2. Legg-Perthes disease
3. Long-term use of corticosteroids
4. Sickle-cell disease
Ans. 1
Avascular necrosis is an infarction of bone that is
associated with (1) long-term corticosteroid use, such as in
patients with systemic lupus erythematosus (most
common cause), (2) sickle-cell disease, (3) trauma, (4)
Legg-Perthes disease, or (5) Kienbock disease involving
the scaphoid (navicular) bone. OsgoodSchlatter dis ease is
a localized inflammation that produces pain in the tibial
tuberosity at the point of attachment of the patellar
tendon, which results in prominence of the tibial
tuberosity that persists throughout life. It usually occurs
during the pubertal growth spurt and is not an example of
avascular necrosis.
119. Which of the following is the LEAST likely
symptom of hyperthyroidism in a 77-year-old man?
1. Atrial fibrillation
2. Confusion
3. Tremor
4. Weakness
Ans. 3
One of the most important principles of caring for the
older patient is the recognition that diseases present in an
atypical fashion. For example, hyperthyroidism in a young
or middle-aged individual usually manifests as tremor,
goiter, or exophthalmos. Instead, this endocrinopathy in an
older person is more likely to cause one of the "final
common pathway" symptoms such as weakness, fatigue,
syncope, confusion, or depression Atrial fibrillation is also
a more typical presentation of hyperthyroidism in this age
cohort than any of the classic symptoms or findings. The
differential diagnosis of a limited number of presenting
symptoms in the elderly is both broad and similar amongst
several syndromes: incontinence, falling, syncope, and
confusion. More over, due to decreased physiologic
reserve in the elderly, patients often present at an earlier 1. Adequate analgesia
stage of the disease. 2. Reduced blood loss
3. Reduced stress response of surgery
120. The pressure used in pneumatic tourniquet in 4. Slow onset
upper limb is upto:
1. Systolic Blood Pressure + 50 Ans. 4
2. Systolic Blood Pressure + 75 Advantages of epidural anaesthesia
3. Systolic Blood Pressure + 100 - Profound analgesia
4. None of the above - Profound muscle relaxation
- No need for intubation
Ans. 2 - Reduction of surgical haemorrhage
Pneumatic tourniquet is a narrow rubber bag to be wound - Excellent post operative analgesia
around a limb, pressure being applied by pumping air into - Reduced stress and response
the inflatable cuff.
A bloodless field is obtained by applying pressure through 125. Which of the following inhalational agent is the
pneumatic tourniquet for accurate surgery. Usually most soluble in blood?
pressure applied 75 mmHg over systolic blood pressure 1. Halothane
for not more than 2 hours. 2. Isoflurane
3. Enflurane
121. In hypotensive patients, Induction of 4. Desflurane
anaesthesia should be done with:
1. Propofol Ans. 1
2. Ketamine Blood/gas partition coefficient: The ratio of concentration
3. Thiopentone in blood to that in gas. High value denotes an agent very
4. Any of the above soluble in blood.
Inhalational agent Blood/gas partition
Ans. 2 coefficient
Ketamine produce a state of Dissociative anaesthesia Halothane 2.30
ketamine increase systolic and diastolic blood pressure, Isoflurane 1.40
increases heart rate and intracranial tension. Enflurane 1.90
Ketamine is good as induction agent for hypotensive Desflurane 0.42
patient. Sevoflurane .69

122. Induction agent, having anti-emetic property Most soluble in blood is halothane.
is: Least soluble in blood is desflurane.
1. Thiopentone
2. Methohexitone 126. The only condition associated with X-linked
3. Propanidid recessive inheritance is:
4. Propofol 1. Phenylketonuria
2. Mucopolysaccharidosis
Ans. 4 3. Achondroplasia
Propotol is used as induction agent, it cause decrease in 4. Marfan's syndrome
blood pressure heart rate and vascular resistance.
Nausea and vomiting is very rare (1 -2%), and less than . Ans. 2
with most other used agents. 1. X-linked recessive inheritance
Hemophilia-A
123. Laryngospasm under anaesthesia can be Muscular dystrophy
relieved by: Mucopolysaccharidosis type II (Hunter syndrome)
1. Aminophylline Colour blindness
2. Salbutamol G6PD deficiency.
3. Terbutaline
4. Succinylcholine 2. X-linked dominant inheritance
Hypophosphatemic rickets
Ans. 4 Incontinentia pigmenti.
Suxamethonium is depolarizing relaxant, used to revert
the spasm under anaesthesia. 3. Autosomal recessive inheritance
Sickle cell anaemia
124. Advantage of epidural anaesthesia includes all 0-thalassemia
except: Wilson's disease

25
Xeroderma pigmentosa
Inborn error of metabolism (Alkaptonuria,
Phenylketonuria, Lysosomal storage disease)
Galactosemia.
4. Autosomal dominant inheritance
Adult polycystic kidney
Neurofibromatosis
Marfan's syndrome (long thin extremities, ectopia
lentis, aortic aneurysm)
Osteogenesis imperfecta
Familial hypercholesteremia
A chondrodysplasia and familial polyposis coli.
127. Typical febrile seizures are characterized by all
of the following except.
1. Commonest cause of seizures In children
2. Seizures do not last for more than minutes
3. E.E.G. shows persistent abnormality
4. No postictal neurological deficit t
Ans. 3
Febrile convulsions are the commonest cause of seizures
during early childhood.
These convulsions are not related to degree of
temperature but frequent if temperature rises abruptly.
The Febrile convulsion
i. Simple or benign
ii. Complex or atypical
Characteristics of simple benign febrile convulsion
The fits occur within 24 hours of onset of fever last less
than 10 minutes
Convulsions are generalized (mostly not always)
No postictal neurological deficit
EEG (electroencephalogram) is normal after few days of
seizure
The age of onset usually between 6 months and 5 years.
Atypical febrile seizures:
Characterised by presence of family history of epilepsy.
Neurodevelopment retardation
Convulsion due to organic neurological damage are
precipitated by fever, as the cerebral threshold for seizures
is reduced with elevation of temperature.
128. A 15-month-old girl has a history of poor oral
fluid intake, occasional vomiting, rapid breathing,
and decreased urine output. Physical examination
reveals a pulse of 150/min, BP of 120/80, and a
respiratory rate of GO/min. There are bibasilar
rales, and the liver is palpable. All procedures
might be helpful in evaluating the oliguria EXCEPT
1. Giving a fluid challenge with isotonic saline, 20
ml/kg
2. Determining the urine sodium concentration
3. Determining the BUN and serum creatinine levels
4. Giving a dose of intravenous furosemide
Ans. 1
26
Despite the history of poor intake of oral fluid, this infant
presents with signs of congestive heart failure and fluid
overload. In view of these findings, a fluid challenge could
be dangerous, and it is unlikely that she would respond. If
the oliguria is the result of congestive heart failure and
poor renal perfusion, the urine sodium concentration and
fractional excretion of sodium should be low, the blood
urea nitrogen and serum creatinine should be normal or
slightly elevated, and the child may respond well to
furosemide.
129. Proper management of a child with an
absolute neutrophil count (ANC) of 100/mm3
would be
1. The start of broad-spectrum intravenous
antibiotics
2. Careful physical examination and chest
radiograph; close observation pending result of
blood cultures
3. Granulocyte transfusion
4. Nutritional support with oral iron and
intramuscular injection or vitamin B 12
Ans. 1
A child with an absolute neutrophil count (ANC) of
100/mm3 is severely neutropenic and is at risk of death
from overwhelming septicemia. Because most signs of
infection (e.g., pneumonitis, pyuria) depend on the
presence of neutrophils, serious infection may be present
in such a patient without producing characteristic physical,
radiologic, or laboratory findings. Thus, broad spectrum
antibiotics (to treat a variety of possible infections) must
be initiated promptly after cultures are obtained. Deferring
treatment until culture results are available may result in
overwhelming septicemia and death. Granulocyte
transfusions usually are not beneficial in these patients
because of the short survival time of the cells in the
bloodstream (plasma half-life is approximately 7 hours).
Iron and vitamin B12 are treatments for nutritional
anemias and are of no therapeutic' value in neutropenia.
130. The most likely diagnosis is
1. Histiocytosis X
2. Rhabdomyosarcoma
3. Neuroblastoma
4. Wilms tumor
Ans. 3
This is a typical presentation of stage IV neuroblastoma,
with the primary tumor arising from orie of the
paravertebral sympathetic ganglia and metastasizing to
bone marrow, cortical bone, and the retro orbital tissues.
Histiocytosis X may have a somewhat similar presentation
and involve multiple bones, but it usually involves one
rather than both orbits; the right flank mass and tumor
clumps in the marrow of this patient also are not
characteristic" of histiocytosis X. Rhabdomyosarcoma may
arise in the orbit but usually is unilateral; the tumor also
rarely is associated with systemic metastases at initial
diagnosis. Wilms tumor would produce a right renal rather
than suprarenal mass and would metastasize to the lungs
rather than to bone and bone marrow. Lymphoblastic
lymphoma usually arises in the anterior mediastinum or
peripheral node's. Even if it were to present with
widespread dissemination, abdominal rather than thoracic
disease would be unusual and Lymphoblasts rather than
tumor clumps would be seen in the marrow.
131. A newborn infant with ambiguous genitalia is
found to have a 46, XX karyotype All of the
following are diagnostic possibilities Except
1. 21-hydroxylase deficiency
2. Partial androgen resistance syndrome
3. True hermaphroditism
4. Maternal virilizing tumor
Ans. 2
Infants with partial androgen resistance may have
ambiguous genitalia, but the karyotype. is 46,XY. These
infants have testes and high levels of testosterone, which
are incompletely effective in Virilizing the external
genitalia in a normal male pattern. The defect is at the level
of the androgen receptor. Female infants with congenital
adrenal hyperplasia due to 21-hydroxylase deficiency may
exhibit a variable degree of masculinization of the external
genitalia because of prenatal exposure to high levels of
circulating adrenal androgens' Most infants with true
hermaphroditism have a 46,XX karyotype. However,
gonadal tissue includes both ovarian and testicular
elements. The testicular androgens cause external
virilization, leading to ambiguous genitalia. In a similar
fashion, a maternal Virilizing tumor may expose a female
fetus to high levels of androgen.
132. All of the following are characteristics of Rett
syndrome EXCEPT
1. Autistic behavior
2. Microcephaly
3. Peculiar wringing motion of the hands
4. Autosomal recessive inheritance
Ans. 4
The genetics of Rett syndrome has not yet been
determined. Although it is thought to be a genetic syn-
drome, no inheritance pattern and no enzymatic deficiency
or other metabolic explanation has been established for
Rett syndrome. The other characteristics (autistic
behavior, microcephaly, peculiar wringing motion of the
hand, dementia) are common in patients with this
disorder.
133. Which of the following is the most likely
associated laboratory abnormality in a patient
suffering from arsenic poisoning?
1. Neutropenia
2. Macrocytic anemia
3. Normocytic anemia
4. Prolongation of the QT interval
27
Ans. 4
Occupational exposure to arsenic may Occur in the
smelting industry (due the presence of arsenic as a
byproduct of purifying ores) and the microelectronics
industry due to the use of gallium arsenate. Inorganic
arsenic (currently used successfully and safely for the
treatment of patients with acute promyelocytic leukemia)
is more toxic than organic arsenic. Arsenic is rapidly
cleared form the GI tract, kidneys, and lungs, where it
originally resides, but leaves a long-term residue in the
integument. Acute arsenic toxicity manifests as increased
vascular permeability and intestinal inflammation.
Cardiomyopathy may be seen with chronic exposure, with
conduction system disease, including QRS widening, ST
prolongation, and multifocal atrial tachycardia. Treatment
of chronic poisoning should include chelation with
dimercaprol.
134. A 45-year-old man present7 with a daily
headache over the past 3 weeks. Each attack lasts
about an hour and awakens the patient from sleep.
It is associated tearing and reddening of his right
eye. The pain is deep, excruciating, and limited to
the right side of the head. The neurologic
examination is normal. The most likely diagnosis:
1. Migraine headache
2. Cluster headache
3. Tension headache
4. Brain tumor
Ans. 2
Cluster headaches, which can cause excruciating
hemicranial pain, are notable for their occurrence during
characteristic episodes. Usually attacks occur during a 4-
to 8-week period in which the patient experiences one to
three severe brief headaches daily. There may then be a
prolonged pain-free interval before the next episode. Men
between ages 20 and 50 are most commonly affected. The
unilateral pain is usually associated with lacrimation, eye
reddening, nasal stuffiness, ptosis, and nausea. During
episodes alcohol may provoke the attacks. Even though the
pain caused by brain tumors may awaken a patient from
sleep, the typical history and normal neurologic
examination do not mandate evaluation for a neoplasm of
the central nervous system. Acute therapy for a cluster
headache attack consists of oxygen inhalation, although
intranasal lidocaine and subcutaneous sumatriptan may
also be effective. Prophylactic therapy with prednisone,
lithium, methysergide, ergotamine, or verapamil can be
administered durinq an episode to prevent further cluster
headache attacks.
135. Which of the following colonic pathologies is
thought to have no malignant potential?
1. Ulcerative colitis
2. Villous adenomas
3. Familial polyposis
4. Peutz-Jeghers syndrome

Ans. 4
Peutz-Jeghers syndrome is characterized by intestinal
polyposis and melanin spots of the oral mucosa. Unlike the
Adenomatous polyps seen in familial polyposis, the lesions
in this condition are hamartomas, which have no
malignant potential.
136. During an operation for carcinoma of the hepatic
flexure of the colon, an unexpected discontinuous 3-
cm metastasis is discovered in the edge of the right
lobe of liver. The surgeon should
1. Terminate the operation, screen the patient for
evidence of other metastases, and plan further therapy
after the reevaluation
2. Perform a right hemicolectomy and right hepatic
lobectomy
3. Perform a right hemicolectomy and a wedge resection
of metastasis
4. Perform a cecostomy and schedule reoperation after a
course of systemic chemotherapy
Ans. 3
Because approximately 5% of colorectal cancers are
associated with resectable hepatic metastases, appropriate
preoperative- discussion should include obtaining
permission for removal of synchronous peripheral hepatic
lesions if they are found. If gross tumor is removed, a 25%
cure rate can be anticipated. Adequate local resection,
either by wedge or by limited partial hepatectomy, may be
carried out whenever no extrahepatic disease is found and
the hepatic lesion is technically removable. Any option that
leaves the potentially obstructing primary cancer
unremoved would be unacceptable.
137. A 62-year-old man has had back pain for 4
months. No abnormal findings are noted on physical
examination. A CBC shows a WBC count of
3700/microliter, hemoglobin 10.3 g/dL, hematocrit
31.1%, MCV 85 fL, and platelet count
110,000/microliter. His total serum protein is 8.5
gm/dl with an albumin of 4.1 gm/dl. A chest
radiograph shows no abnormalities of heart or lung
fields, but there are several lucencies noted in the
vertebral bodies. A sternal bone marrow aspirate is
performed and yields a dark red jelly-like material in
the syringe. Which of the following cell types is most
likely to be numerous on microscopic examination of
this aspirate?
1. Giant cells
2. Fibroblasts
3. Osteoblasts
4. Plasma cells
CORRECT 4. The patient has multiple myeloma. The bone
marrow needle was in a lytic lesion filled with plasma cells.
His serum globulin is high as a result of his monoclonal
gammopathy.
Incorrect 1. Giant cells may be seen in a variety of benign
28
and malignant lesions of bone, but this does not explain
the hypergammaglobulinemia.
Incorrect 2. Fibroblasts produce collagen and are more
numerous with the gross appearance of firm, white scar
tissue.
Incorrect 3. Osteoblasts are most numerous in repair of
bone, and callus is very firm.
138. Mixed tumors of the salivary glands are
characterized by which of the following?
1. They occur most commonly on the lips, t09gue, and
palate
2. They grow rapidly
3. They rarely recur if simply enucleated
4. They present as rock-hard masses
Ans. 1
There are approximately 400 to 700 minor salivary glands
in the oral cavity. Pleomorphic adenomas (mixed tumors)
can occur in any of them. These round tumors have a
rubbery consistency and are slow-growing; all are
potentially malignant. Unless adequately excised, they tend
to recur locally in a high percentage of cases. The sites
most commonly affected by pleomorphic adenomas of the
salivary glands are the lips, tongue, and palate.
139. The primordial germ cells that eventually from ,
the oogonia and spermatogonia originate in which of
the following
1. Dorsal mesentery of the hindgut
2. Gonadal ridge
3. Endodermal lining of the yolk sac
4. Primary sex cords of the developing gonad
Ans. 3
The primordial germ cells are first seen in the endodermal
lining of the wall of the yolk sac (derived from the
hypoblast) at the end of the third or beginning of the
fourth week in the region of the allantois. During
embryonic folding, the dorsal part of the yolk sac is
incorporated into the embryo as the primitive gut. The
primordial germ cells subsequently migrate along the
dorsal mesentery of the hindgut and into the gonadal
(genital) ridge by week 6. The primary sex cords grow into
the mesenchyme underlying the ridge, and the primordial
germ cells become incorporated into the primary sex
cords. The chorion is the outermost fetal membrane and is
composed of extraembryonic somatic mesoderm,
cytotrophoblast, and the syncytiotrophoblast. It is divided
into the chorion frondosum, where the villi form and
proliferate. and the smooth chorion, also known as the
chorion laevae. The following diagram illustrates the
arrangement of the fetal membranes.
The primordial germ cells are the common
origins of spermatozoa and oocytes and thus
represent the ancestors of the germline. Like all
other somatic cells these are diploid and in
human embryos can already be found in the
 primary ectoderm (epiblast) in the second
week.
140. Members of the multi pass, G protein-linked
family of receptors include the muscarinic cholinergic
and J3-adrenergic receptors and rhodopsin. Which of
the following characterizes these receptors?
1. They possess a single hydrophobic transmembrane
segment in the form of an a helix
2. They can activate plasma membrane-bound enzymes
or ion channels
3. They posses an intracellular ligand-binding domain
4. They possess intrinsic enzyme activity
Ans. 2
Binding of ligand to the multipass G protein-linked
receptors activates or inactivates enzymes bound to the
plasma membrane (adenylyl cyclase or phospholipase C)
or opens or closes ion channels using G proteins. A table of
G proteins and their functions appears below. The
muscarinic cholinergic and receptors, as well as
rhodopsin, are multipass transmembrane proteins
consisting specifically of seven hydrophobic spanning
segments of the single polypeptide chain. The peptide
bonds of the spanning segments are polar. In the
hydrophobic environment of the lipid bilayer, in the
absence of water, they form hydrogen bonds with each
other. In the vast majority of cases this leads to the
formation of ex helices. In the case of the porins, found in
the outer mitochondrial membrane, a 0-barrel structure is
established. There is a remarkable homology between the
cell-surface receptors linked to the G proteins. Between
the segments, the polypeptide chain loops on both the
extracellular and the intracellular sides of the membrane.
Ligand binding occurs on the extracellular surface.
Receptors with intrinsic enzyme activity belong to a
separate class of singlepass transmembrane proteins. All
of these transmembrane proteins show a carboxyl
terminus on the cytosolic side and N-linked glycosylation
sites on the extracellular surface.
141. Which of the following events occurs in the rough
endoplasmic reticulum?
1. Core glycosylation of proteins
2. O-linked glycosylation
3. Sulfation
4. Protein sorting
Ans. 1
The rough endoplasmic reticulum (RER) is the site of core
glycosylation of proteins using the membrane-bound lipid
carrier, dolichol, catalyzed by an oligosaccharide
transferase. This is N-linked glycosylation, which occurs by
an en bloc method in which dolichol is added to the
protein. O-linked glycosylation occurs in the Golgi (answer
b) by a mechanism involving oligosaccharide (glycosyl)
transferases rather than en bloc. N linked oligosaccharides
are the most common oligo saccharides found in
glycoproteins and contain sugar residues linked to the
29
NH2 amide nitrogen of asparagine. 0linked
oligosaccharides have sugar residues linked to hydroxyl
groups on the side chains of serine and threonine and are
less common than the N-linked species.
142. Meiotic crossover occurs in which of the
following?
1. Leptotene
2. Zygotene
3. Pachytene
4. Diplotene
Ans. 3
Crossover occurs during the pachytene stage of meiosis.
Meiosis is the mechanism used by the reproductive organs
to generate gametes-cells with the haploid number of
chromosomes. DNA synthesis occurs before meiotic
prophase begins and is followed by a G2 phase. Cells then
enter meiotic prophase I. During meiotic prophase I,
maternal and paternal' chromosomes are precisely paired,
and recombination occurs in each pair of homologous
chromosomes. The first meiotic prophase consists of five
substages: leptotene, zygotene, pachytene, diplotene, and
diakinesis. During metaphase I, there is random
segregation of maternal and paternal chromosomes.
Homologous chromosomes are aligned on the metaphase
plate of the meiotic spindle in metaphase I. The second
meiotic division is responsible for the reduction in the
chromosome content of the cell by 50%. In meiotic
division II, metaphase consists of daughter chromatids of
single homologous chromosomes aligned on a metaphase
plate (metaphase II). Condensation of the chromatids
occurs in leptotene. In zygotene, the synaptonemal
complex begins to form, which initiates the close
association between chromosomes known as synapsis. The
bivalent is formed between the two sets of homologous
chromosomes (one set maternal and one set paternal
equals a pair of maternal chromatids and a pair of paternal
chromatids). The four chromatids form a tetrad (bivalent).
Pachytene begins as soon as the synapsis is complete and
includes the period of crossover. The fully formed
synaptonemal complex is present during the pachytene
stage. At each point where crossover has occurred
between two chromatids of the homologous chromosomes,
an attachment point known as a chiasma forms. The
formation of chiasmata and de synapsing (separation of
the axes of the synaptonemal complex) occurs in the
diplotene stage. Diakinesis is an intermediate phase
between diplotene and metaphase of the first meiotic
division.
143. Vitamin C deficiency results in which of the
following?
1. Decreased degradation of collagen
2. Stimulation of poly hydroxylase
3. Formation of unstable collagen helices
4. Excessive callus formation in healing fractures
Ans. 3
Scurvy, or vitamin C deficiency, results in an inability to
form normal collagen triple helices. In scurvy, the resulting
collagen is less stable and is subject to denaturation and
proteolytic breakdown. That results partially from slower
secretion of collagen from fibroblasts. The collagen formed
is not normally hydroxylated at proline and lysine residues
because of the absence of vitamin C, which is a specific
cofactor for hydroxylation of proline and lysine. Bone
growth, development of the dentition, and wound and
fracture healing as well as the general stability of adult
organs are inhibited because of the importance of collagen
in the maintenance of structural support. Periodontal
bleeding and ulceration are also common symptoms in
scurvy.
144. In a positive tuberculin skin test, helper T cells
assist in which of the following ways?
1. Autocrine-mediated inhibition of proliferation of
helper T cells
2. The down regulation of IL-2 receptors on helper T
cells
3. Secretion of interleukins that promote T cell
proliferation
4. Secretion of IL-I
Ans. 3
In a tuberculin skin test, T cell proliferation is increased by
secretion of interleukins. An extract of tuberculin (an
antigen of lipoprotein composition obtained from the
tubercle bacillus) is injected into the skin of a person who
has had tuberculosis or has been immunized against
tuberculosis. Merriory helper T cells react to the
tuberculin and secrete Il-2, which up regulates Il-2
receptors. Il-2 binding to Il-2 receptors on the same cell is
an example of autocrine regulation in which a cell secretes
a ligand for a receptor on its own surface. The result of this
up regulation and ligand receptor binding is an increase in
T cell proliferation. T cell derived cytokines such as tumor
necrosis factor-alpha and beta (TN F and ) induce
leukocyte recruitment. Production of gamma-()-
interferon by helper T cells attracts and activates
macrophages (monocytes comprise most of the cellular
infiltrate). -Interferon also converts other cells (such as
endothelial cells) to antigen-presenting cells by induction
of class II MHC expression, which further augments the
response. The result of the activity of helper T cells is a
dramatic increase in the number of lymphocytes and
macrophages at the test site, which produces swelling. IL-I
is synthesized by antigen-presenting cells and macro
phages with helper T cells as the targets.
145. Which of the following are characteristic of the
secretory phase of the menstrual cycle?
1. It precedes ovulation
2. It depends on progesterone secretion by the corpus
luteum
3. It coincides with the development of ovarian follicles
4. It coincides with rapid drop in estrogen levels
30
Ans. 2
The secretory phase of the menstrual cycle depends on
progesterone secretion and follows the proliferative
(follicular) phase. The menstrual phase occurs after the
secretory phase. During the follicular phase
(approximately days 4 to 16), estrogen produced by the
ovaries drives cell proliferation in the base of endometrial
glands and the uterine stroma. The proliferative phase
culminates with ovulation. The secretory phase
(approximately days 16 to 25) is characterized by high
progesterone levels from the corpus luteum, a tortuous
appearance of the uterine glands, and apocrine secretion
by the gland cells. During this phase, maximum
endometrial thickness occurs. The menstrual phase
(approximately days 26 to 30) is characterized by
decreased glandular secretion and eventual glandular
degeneration because of decreased production of both
progesterone and estrogen by the theca lutein cells.
Contraction of coiled arteries and arterioles leads to
ischemia and necrosis of the stratum functionale.
146. Which of the following is directly involved in
sound transduction?
1. Release of neurotransmitter onto the afferent endings
of cranial nerve VIII
2. Shearing motion of the basilar membrane against hair
cell stereocilia
3. Movement of the tectorial membrane resulting in hair
cell depolarization
4. Vibration at the round window via the stapes
Ans. 1
Shearing of the hair cell stereocilia against the tectorial
membrane results in depolarization, and the release of
neurotransmitter onto afferent endings of the auditory
cranial nerve leads to initiation of an action potential.
Sound waves are directed toward the tympanic membrane
by the pinna and the external auditory canal of the
external ear. The vibration of the tympanic membrane is
transmitted to the oval window by way of the ossicles of
the middle ear. Induction of waves in the perilymph results
in the movement of the basilar and vestibular membranes
toward the scala tympani and causes the round window to
bulge outward. The movement of the hair cells is
facilitated because the tectorial membrane is rigid and the
pillar cells form a pivot. The stabilization of the pressure
between the middle ear and the nasopharynx is not
directly related to the mechanism of sound transmission.
147. A patient has extremely enlarged palatine tonsils.
You suggest surgical removal of the tonsils, but you do
explain that there is a small risk of the surgery, which
may result in which of the following?
1. Loss in the ability to taste salt in the anterior two-
thirds of the tongue
2. Loss in the ability to protrude her tongue, thus limiting
her ability to lick an ice cream cone
3. Weakness in the ability to open her mouth fully when
eating an apple due to damage to the innervation to
the lateral pterygoid muscle
4. Loss in the ability to taste in the posterior one-third of
the tongue and perhaps some difficulty in swallowing
Ans. 4
The palatine tonsil sits in the lateral wall of the
oropharynx in the palatine arch posterior to the
palatoglossus muscle and anterior to the
palatopharyngeus muscle. In the bed of the palatine tonsil
runs the glossopharyngeal CN (IX) that carries afferent
information back to the brain regarding both general
sensation and the special sense of taste from the posterior
one-third of the tongue. The glossopharyngeal nerve is at
risk for being cut during tonsillectomy. The ability to taste
in the anterior two-thirds of the tongue is not at risk
because that information is carried by the lingual nerve,
below the tongue. The ability to protrude your tongue is
provided by innervation from the hypoglossal nerve,
which innervates all the intrinsic tongue muscles and lies
below the tongue and is not a risk. Neither the ability to
open your jaw wide nor to move your jaw from side to side
is controlled by the mandibular division of the trigeminal
CN (V), which does not course near the palatine arch and
would not be at risk.
148. Which muscle is a pure elevator of the jaw?
1. Buccinator muscle
2. Geniohyoid muscle
3. Lateral pterygoid muscle
4. Medial pterygoid muscle
Ans. 4
The medial pterygoid muscle, which originates on the
medial side of the lateral pterygoid plate, and the masseter
muscle, which originates from the zygomatic arch, pass
medially and laterally to the ramus of the mandible to form
a sling about the angle of the mandible. These muscles are
powerful elevators of the jaw. The muscle bundles of the
anterior portion of the temporalis muscle run nearly
vertically into the coronoid process of the mandible, acting
as a jaw elevator. The lateral pterygoid muscles run from
the lateral side of the pterygoid plate and from the
infratemporal fossa to the head of the mandible and the
articular disk of the temporomandibular joint. Contraction
of the lateral pterygoid muscles bilaterally protrudes the
jaw. Unilateral contraction swings the jaw toward the
opposite side. The submental muscles, assisted by gravity,
are the primary depressors of the jaw. These include the
geniohyoid and mylohyoid muscles as well as the anterior
belly of the digastric muscle, all of which function in
conjunction with the infrahyoid strap muscles.
149. Which of the following statements is true of
cardiac development?
1. During formation of the heart loop, a single-tube heart
remains suspended by a complete dorsal
mesocardium (mesentery)
31
2. The atria are represented by cranial portions of
endocardial tubes
3. The heart bends into an S-shape because the caudal
regions of the endocardial tubes grow faster than the
cranial regions
4. The left and right sides of the heart result directly
from the side-by-side apposition
Ans. 3
The heart forms during the third week by the apposition of
left and right endocardial tubes as the head fold progresses
caudally The endocardial tubes fuse to form a single-tube
heart. This fusion begins cranially in the region of the
bulbus cordis (outflow trunks) and proceeds caudally
through the ventricles and the atria to the sinus venosus,
which is incorporated into the atrium after loop formation.
Rapid proliferation of the ventricular region results in the
single-tube heart bending into an S-shaped loop. During
this process, the dorsal mesocardium partially breaks
down, which leaves the heart suspended only at the cranial
and caudal ends; the discontinuity in the mesocardium is
the transverse sinus. The left and right sides of the heart
are established by the subsequent division of the single
tube heart, not by the apposition of left and right
endocardial tubes.
150. All of the following statements about keloids are
true except:
1. A keloid does not regress spontaneously
2. A keloid extends beyond the boundaries of the original
wound.
3. Keloids or hypertrophic scars are best managed by
excision and careful reapproximation of the wound
4. Keloid tissue contains an abnormally large amount of
collagen
Ans. 3
Keloids and hypertrophic scars both occur aftet injuries
operations. Hypertrophic scars remain confined to the
original injury site and usually regress spontaneously. By
contrast, keloids extend beyond the original wound and
rarely regress. Keloids contain abnormally large amounts
of soluble collagen and water. Keloids tend to recur after
excision, and any surgical therapy should be undertaken
cautiously with the patient aware that the result may not
be ideal.
151. A 20-yrs-old man suffers an injury to the
posterior urethra. After appropriate initial
management and follow-up care of this injury, the
most likely late complication is:
1. Ascending urinary tract infection
2. Retrograde ejaculation
3. Sterility
4. Urethral stricture
Ans. 4
Initial management involves passage of catheters through
the urethral meatus and through an incision in the bladder.
After this has been accomplished, a Foley catheter is
threaded through the urethra into the bladder and left in
situ. Urethral healing occurs as the hematoma resolves, but
a posterior urethral stricture is not uncommon. If the
stricture is not managed appropriately, ascending urinary
tract infection may result.
152. Which of the following changes is most likely to
occur following administration of an ACEI?
1. Increased levels of rennin
2. Increased levels of angiotensin
3. Increased levels of aldosterone
4. Increased levels of ADH
Ans. 1
Inhibition of angiotensin-converting enzyme (ACE)
reduces angiotensin II formation. As a result, those
pathways that are stimulated by angiotensin II are also
reduced. The most important change is a reduction in the
release of aldosterone. To a lesser extent, angiotensin II
also causes vasoconstriction and release of transmitter
from sympathetic nerves, and these direct excitatory
effects are also reduced. Finally, angiotensin II has some
direct excitatory effect on antidiuretic hormone (AD H)
release. Lowering angiotensin II may therefore slightly
reduce ADH levels by this direct mechanism. These effects
tend to reduce blood pressure and volume. This reduction
is sensed by pressure and volume sensors throughout the
body, leading to enhanced renin release. The effect of ACE
inhibitors on ADH levels is complicated. On one hand,
angiotensin II has a small direct stimulatory effect on ADH
release, so blockade of angiotensin II synthesis tends to
limit ADH release. Furthermore, to the extent that more
salt than water is lost, plasma osmolaliry decreases,
leading to a de- crease in ADH levels. On the other hand,
any reduction in extracellular fluid volume tends to
enhance ADH levels. In summary, only minor changes in
ADH levels are expected whereas a significant rise in
plasma renin levels occurs.
153. The ureter lies against the anterior surface of
which of the following muscles?
1. Crus of the diaphragm
2. Quadratus lumborum
3. Psoas major
4. Transversus abdominis
Ans. 3
The ureter exits the renal pelvis at about the level of
vertebra L2. As it descends along the posterior abdominal
wall, it lies on the anterior surface of the psoas major. The
psoas major muscle arises from the bodies of the lower
lumbar vertebrae. The psoas major muscle is joined by the
iliacus to form the iliopsoas muscle. The iliopsoas muscle
then attaches to the lesser trochanter of the femur and is
the major flexor of the hip.
32
154. A 48-yrs-old male alcoholic with bilateral
gynecomastia. Which physical findings has cirrhosis
has the same pathogenesis as gynecomastia?
1. Caput medusa
2. Asterixis
3. Ascites
4. Spider angioma
Ans. 4
Gynecomastia in male cirrhotics is caused by
hyperestrinism secondary to the inability of the liver to
metabolize estrogens. Hyperestrinism results in the
development of female secondary sex characteristics,
palmar erythema, spider angioma, and testicular atrophy
caused by decreased testosterone.
155. Decreased activity of type I 5'-monodeiodinase
could lead to which physiologic effects:-
1. Increased plasma triiodothyronine (T3)
2. Increased plasma reverse T3
3. Decreased plasma thyroxine T4
4. Increased TSH
Ans. 2
Type I 5'-monodeiodinase is the enzyme responsible for
the peripheral conversion of thyroxine (T4) to
triiodothyronine (T3), primarily in liver and kidney. This
enzyme also participates in the breakdown of reverse T3
(rT3) by converting it to 3,3'-diiodothyro nine. Decreased
activity of type I 5'-monodeiodinase will therefore
decrease plasma levels of T3 and increase plasma levels of
rT3 (by decreasing its breakdown). Type II 5'-
monodeiodinase is present in the anterior pituitary and
central nervous system. Conversion of T 4 to T 3 within the
anterior pituitary by this enzyme is responsible for normal
feedback inhibition of thyroid stimulating hormone (TSH)
secretion. With decreased type I 5'-monodeiodinase
activity, plasma levels ofT4 and TSH usually stay within
normal limits because the type II enzyme continues to
insure normal feedback inhibition by anterior pituitary T
3.
156. A pregnant woman with the recent onset of
urinary frequency, urgency and dysuria, and evidence
of bacteriuria should be treated with:
1. Ciprofloxacin
2. Norfloxacin
3. Trimethoprim-sulfamethoxazole
4. Cephalexin
Ans. 4
Tetracyclines may cause staining of fetal teeth when given
during pregnancy. Trimethoprim sulfamethoxazole may
cause neonatal jaundice when administered late in
pregnancy because sulfonamides may displace bilirubin
from plasma proteins. Fluoroquinolones, such as
ciprofloxacin and norfloxacin, are best avoided in
pregnancy because of their potential to cause arthropathy
in the fetus caused by damage to cartilage. The 13-lactam
antibiotics, including penicillin's such as ampicillin and
various oral cephalosporin's, may be safely administered
to pregnant women. First- or second-generation
cephalosporins are usually preferred because of their
antimicrobial spectrum.
157. A patient presents to a clinic with complaints of
headache fatigue. Lab data show serum sodium, 122
mEq/L; serum osmolality, 240 mOsm/L; urine
osmolality, 455 mOsm/L. which condition best
correlates with these data?
1. Neurogenic diabetes insipidus
2. Nephrogenic diabetes insipidus
3. Diabetes mellitus
4. SIADH
Ans. 4
Hyponatremia, hypo-osmolality, and inappropriately
concentrated urine are characteristic of SIADH. The
syndrome results from excessive secretion of vasopressin.
This could be due to ectopic tumor secretion of
vasopressin, various central nervous system
complications, or it could be drug induced. The increased
vasopressin causes excessive water retention, resulting in
dilutional hyponatremia and hypo-osmolality. Volume
expansion inhibits the renin- angiotensin system. Plasma
aldosterone therefore tends to be low, which partly
explains the inappropriately concentrated urine.
158. Which of the following clinical findings is more
likely to be associated with acute rather than chronic
glomerulonephritis?
1. Osteomalacia
2. Increased anion gap metabolic acidosis
3. Oliguria
4. Preservation of concentrating ability
Ans. 4
Acute glomerulonephritis is more likely to be associated
with preservation of concentrating ability than chronic
glomerulonephritis, in which tubular dysfunction is
present. Osteomalacia, the inability to mineralize osteoid,
is more likely to occur in chronic glomerulonephritis
because of the loss of vitamin D synthesis in the tubules.
Increased anion gap metabolic acidosis is more likely to
occur in chronic glomerulonephritis, because tubular
function and the ability to excrete a hydrogen load are
disturbed. Oliguria occurs in both acute and chronic
glomerulonephritis. Casts in the urine are present in both
diseases. However, red blood cell and white blood cell
casts are more likely to be present in acute
glomerulonephritis, whereas waxy and I broad casts are
more likely in chronic glomerulonephritis.
159. Which of the following renal alterations would
most likely preserve the GFR?
1. Defect in the elimination of hydrogen ions in the distal
tubule
2. Luminal obstruction by renal tubular casts
33
3. Increased interstitial pressure
4. Decreased intrarenal nitric oxide
Ans. 1
The renal alteration that would most likely preserve the
GRF is type I distal renal tubular acidosis, in which
hydrogen ions diffuse back into the distal tubule. This not
only retains hydrogen ions, but also reduces the distal
tubule reabsorption of bicarbonate. The other choices
listed are associated with acute tubular necrosis and
decrease the GFR.
160. All of the following structures are normally
palpable upon vaginal examination except the:
1. Uterine tubes
2. Ovary
3. Rectouterine pouch
4. Sacral promontory
Ans. 4
Normally, the sacral promontory is too distant to be
palpable on vaginal examination. If the sacral promontory
is palpable, this indicates that the conjugate diameter of
the pelvis is smaller than normal, and a normal vaginal
delivery may not be possible. The ischial spines are
palpable. This landmark is used for administering a
pudendal nerve block. The pudendal nerve wraps around
the ischial spine and sacrospinous ligament. The
rectouterine pouch is palpable through the wall of the
posterior fornix of the vagina. The ovary and uterine tubes
are palpable in the broad ligament.
161. Which would lead to an increase In hepatocyte
synthesis of primary bile acids?
1. An injection of cholecystokinin
2. An ileal resection
3. Stimulation of the vagus nerve
4. Lovastatin
Ans. 2
The rate of synthesis of primary bile acids from cholesterol
is inversely related to the rate at which bile acids are
extracted from the hepatic portal blood and resecreted
into the bile canaliculi. Therefore, an increase in the rate of
synthesis occurs following ileal resection. Ileal resection
decreases the ability to absorb bile acids from the small
intestine and causes a decrease in enterohepatic
recirculation of the bile acids. Therefore, secretion of new
bile acids is increased. Injection of cholecystokinin or
stimulation of the vagus nerve contract the gallbladder and
relax the sphincter of oddi, causing increased delivery of
bile acids to the duodenum. These bile acids are absorbed
in the ileum and returned to the liver in the hepatic portal
blood. Therefore, synthesis of new bile acids is decreased.
Lovastatin, which decreases the activity of 3 hydroxy3-
methylglutaryle coenzyme A (HMGCoA) reductase,
decreases synthesis of cholesterol and, therefore,
decreases the synthesis of bile acids. A decrease in dietary
cholesterol would decrease the synthesis of primary bile
acids.
162. All of the following statements about the control
of micturition are true except:
1. An individual with a spinal cord injury at L1 can still
have a micturition reflex
2. The micturition reflex can occur without voiding any
urine
3. Bladder volume can be more than double that present
when the first urge to void occurs
4. An individual with destruction of the sacral dorsal
roots can still have a micturition reflex
Ans. 4
Micturition is initiated by activation of afferent sensory
fibers located in the wall of the bladder; these fibers sense
the degree of stretch of the bladder wall. In addition, these
sensory fibers travel back to the spinal cord via sacral
dorsal roots. The sensory information that reaches the
spinal cord also travels to the micturition center in the
rostral pons. When sensory activity to the micturition
center is sufficient, a command is sent to the sacral spinal
cord, leading to activation of parasympathetic fibers. The
parasympathetic fibers travel to the bladder via the pelvic
nerve. Activation of these fibers leads to bladder
contraction. Destruction of the sacral dorsal roots (as
occurs with tabes dorsalis) abolishes the reflex because
sensory afferent fibers no longer send signals back to the
spinal cord.
A spinal cord injury at L1 is well above the sacral region
where the micturition reflex originates. How ever, the
central nervous system (CNS) plays an important role in
facilitating or inhibiting the micturition reflex, and this
function is lost with spinal cord injury. Although some
patients with spinal cord injury can still elicit a micturition
response (e.g., stroking of the skin in the genital region),
the bladder in these patients has increased muscle tone
and fails to empty completely. As the bladder becomes
more and more distended, an involuntary micturition
reflex can occur. However, the CNS can keep urine from
being voided under these circumstances by maintaining a
constant tonic contraction of the external sphincter. This
contraction is accomplished through continued activation
of so matic nerves that travel in the pudendal nerve from
the sacral spinal cord to the external sphincter. The point
at which an urge to void first occurs corresponds to a
bladder volume of approximately 150 ml. However,
bladder volume can increase more than twofold before
involuntary micturition occurs. At 400 ml a marked sense
of fullness is present. Parasympathetic fibers originating in
the sacral spinal cord innervate the body of the bladder,
and it is activation of these fibers that leads to bladder
contraction.
163. The external urethral sphincter is located in
which of the following regions?
1. Ischiorectal fossa
2. Extrapertoneal space
34
3. Retropubic space
4. Deep perineal space
Ans. 4
The external urethral sphincter is the voluntary sphincter
composed of skeletal muscle, the sphincter urethrae
muscle. This muscle, along with the deep transverse
perineal muscle, are in the deep perineal space and form
the muscular layer of the urogenital diaphragm. The
internal urethral sphincter is composed of smooth muscle
in the neck of the bladder. The internal and external
sphincters are both open during micturition. During
ejaculation, the external sphincter is open and the internal
sphincter is closed.
164. All of the following statements concerning ANP
are true except:
1. Its secretion is increased by an increase in blood
volume
2. It increases glomerular filtration rate
3. It inhibits rennin secretion
4. Its effects are mediated by increased cyclic AMP
Ans. 4
ANP is a polypeptide composed of 28 amino acids that is
secreted by endocrine cells in the atria. ANP acts at the
kidney to increase sodium excretion, and is secreted in
response to blood volume expansion or increased sodium
chloride intake. Circulating levels of ANP are increased in
congestive heart failure, a condition in which atrial
pressure is chronically elevated. The exact mechanisms for
the natriuretic effect are not completely known. ANP
increases glomerular filtration rate without a sustained
increase in renal blood flow, which suggests that the
peptide may constrict efferent arterioles. Furthermore,
ANP relaxes mesangial cells in the glomeruli, thereby
increasing surface area available for filtration. Finally, ANP
may directly inhibit sodium reabsorption by renal tubules.
The actions of ANP are generally opposite to those of the
renin-angiotensin-aldosterone system. ANP inhibits the
secretion of renin and aldosterone. ANP produces its
effects by increasing intracellular formation of cGMP. The
ANP receptor has a cytoplasmic domain with guanylyl
cyclase activity, which is increased by hormone-receptor
binding.
165. A 20-year-old sexually active woman presents
with swelling of the vaginal labia. Examination of the
perineal sharply defined subcutaneous bleeding
nodules that appear to erode through the skin. The
most likely etiologic agent in this case is
1. Treponema pallidum
2. Herpes virus
3. Calymmatobacterium
4. Neisseria gonorrhoeae
Ans. 4.
This patient is suffering from donovanosis, a chronic
progressively destructive bacterial infection of the genital
region that was formerly known as granuloma inguinale or
granuloma venereum. This disease is caused by gram-
negative pleomorphic encapsulated intracellular
bacterium called C. granulomatis. Although there may be
some patients who develop this disease on the basis of
nonintimate contact, it is most likely that this is a sexually
transmitted disease. The incubation is usually 1 to 4 weeks
but may be longer. Most patients have disease limited to
the genital area; extragenital lesions occur in about 6%
and may include oral lesions and bleeding and/or bone
disease. Diagnosis involves demonstration of intracellular
Donovan bodies within the mononuclear cells obtained
from a lesion. Syphilitic plaques are usually white rather
than the red lesions characteristic of donovanosis.
Donovanosis lesions can be so necrotic that squamous cell
carcinoma m9Y be considered.
166. Impaired immune competence is the
predisposing factor in about half of all persons who
develop
1. Histoplasmosis
2. Coccidoidomycosis
3. Blastomycosis
4. Cryptococcosis
Ans. 4.
Fungal and yeast infections, predominantly candidiasis,
aspergillosis, and mucormycosis, occur frequently in
severely immunosuppressed patients, particularly those
who have received broad-spectrum antibiotics for a
prolonged period. A number of other types of fungal
infection occur in these patients. About 75% of all cases of
Cryptococcus neoformans infection occur in persons who
have AIDS or lymphoma, are taking glucocorticoids, or are
otherwise immunocompromised. The association of
cryptococcal meningitis and Hodgkin's disease is
important clinically.
167. Which statement concerning the relationship of
T6 and HIV infection is correct?
1. Levels of plasma HIV RNA decrease in the setting of
active TB
2. TB usually develops only when the median CD4 count
is <200uL.
3. Extrapulmonary disease is more common than
pulmonary disease in the HIV infected individual
4. Therapy for TB is the same in the HIV-infected patient
as in the HIV-negative patient.
Ans. 4.
Tuberculosis has experienced a resurgence associated
with the HIV epidemic. In the United States, up to 5% of
patients with AIDS has active TB infection which is more
commonly pulmonary than extra pulmonary. It is
important to recognize and treat TB early in the course of
disease in patients with HIV infection, since TB can
increase the level of HIV RNA in the plasma. Skin testing is
helpful for predicting who is at risk for TB but is not
helpful in the diagnosis of active infection. The epidemic of
35
TB associated with HIV infection is probably the greatest
health risk to the general public and the health care
profession. Though atypical mycobacterial infection occurs
relatively late in HIV infection in patients with low CD4
counts, active typical TB may develop relatively early in
the course of the disease. Patients with relatively high
CD4+ T cell counts may exhibit typical pulmonary
reactivation with the Clinical syndrome of weight loss,
fever, cough, and dyspnea and with a chest x-ray revealing
apical cavitary disease. In patients with lower CD4 + T cell
counts, disseminated disease, including extra pulmonary
manifestations, is more common. Fortunately, the
treatment of active TB in an HIV patient can be quite
successful, and the recommended therapy is generally the
same as it would be in a patient who does not have HIV
infection. However, rifabutin should be substituted for
rifampin in patients who are receiving the protease
inhibitors or nonnucleoside reverse transcriptase
inhibitors because of adverse interactions.
168. Which statement concerning the pathogenesis of
fever is correct?
1. Aspirin inhibits the production of endogenous.
pyrogens
2. The major endogenous pyrogens in human in clued IL-
4 and transforming growth factor-B (TGF-B)
3. Endogenous pyrogens are produced by bacteria,
protozoa, and fungi
4. Endogenous pyrogens play a role in the cachexia of
chronic infections.
Ans. 4.
A host of stimuli, including infection with virtually any
microorganism, cause macrophages, lymphocytes,
fibroblasts, and other cells to elaborate the key
mediators of fever production, such as tumor necrosis
factor (TNF) a, TNF- (lymphotoxin), IPN-, and the
interleukins, which are 17 -kDa glycoproteins that
promote the synthesis of E series prostaglandins in the
hypothalamus and thus reset the central thermostat at a
higher level. Aspirin and nonsteroidal anti-
inflammatory agents act by inhibiting cyclooxygenase
activity so that prostaglandin - (PG-) cannot be
synthesized; they do not act by reducing TNF and
IL1production. Glucocorticoids suppress fever by both
interfering with arachidonic acid metabolism and
downregulating the production of endogenous
pyrogens. TNF and IL-I also possess diverse effects,
including the induction of cachexia by TNF.
169. A 20-year-old woman has mild pulmonary
stenosis. Which of the following statements regarding
this situation is true?
1. Heart size on chest x-ray is likely to be enlarged
2. Electrocardiogram is likely to be abnormal
3. There is loss of the jugular a wave
4. Compared to other valvular defects, the risk of
endocarditis is relatively low
Ans. 4
Adults with mild pulmonic stenosis are generally
asymptomatic. Unlike congenital aortic stenosis, this
condition usually does not progress; thus, follow-up
need not be frequent. The risk of endocarditis is
somewhat lower for pulmonic valves than for the other
heart valves, whether normal or stenotic. Clinical signs
of mild pulmonic stenosis include a prominent a wave
on jugular venous pulse, a normal electrocardiogram,
and normal cardiac size on chest x-ray.
170. Each patient below is alert and oriented and has
a BP110/60. In which patient would adenosine
constitute appropriate initial therapy?
1. A 65-year old man with no ischemic heart disease and
wide complex tachycardia
2. A 65 -year old woman with known ischemic disease
and narrow complex tachycardia
3. A 25-year old woman with known preexcitation
syndrome and narrow complex tachycardia
4. A 28-year-old man with known preexictation
syndrome and wide complex tachycardia
Ans. 2. Adenosine is currently approved for the
termination of paroxysrriat supraventricular tachycardias
at doses of 6 mg and, if 6 mg fails, 12 mg. The primary
mechanism of adenosine is to decrease conduction velocity
through the A V node. As such, it is an ideal drug for acute
termination of regular reentrant supraventricular
tachycardia involving the A V node) Side effects may
include chest discomfort and transier it hypotension. The
half-life is extremely short, and the side effects tend to be
brief. Patients with wide complex tachycardia suggestive
of ventricular tachycardia or known preexcitation
syndrome should be treated with agents that decrease
automaticity, such as quinidine and procainamide.
However, in patients with apparent ventricular
tachycardia who have neither a history of ischemic heart
disease nor preexcitation syndrome, adenosine may be a
useful diagnostic agent to determine whether a patient has
a reentrant tachycardia, in which case the drug may
terminate it; an atrial tachycardia, in which case the atrial
activity may be unmasked; or a true, preexcited tachy-
cardia, in which case adenosine will have no effect. While
adenosine is not the recommended primary therapy for
patients with wide complex tachyarrhythmia, patients
with junctional tachycardia who have evidence of poor
ventricular function or concomitant -adrenergic blockade
may be reasonable candidates for its use.
171. Which ECG findings represents a characteristic
manifestation of digitalis toxicity?
1. ST -segment depression
2. T-wave inversion
3. Atrial flutter
4. Atrial tachycardia with variable block
Ans. 4
36
Digitalis glycosides are effective in increasing
myocardial contractility and in the treatment of certain
atrial tachyarrhythmias. However, digoxin actually
increases myocardial automaticity (increase in premature
beats) and facilitates reentry (atrial tachycardias). Digoxin
also slows conduction through A V nodal tissue and has
central effects that can mimic vagal influence on the heart
and thus may produce sinus arrest. Paroxysmal atrial
tachycardia with variable block represents the classic
rhythm of digitalis intoxication. Digoxin is profibrillatory,
but its administration should not lead to atrial flutter.
Therapeutic levels of digitalis generate characteristic ST-
segment and T-wave changes in most individuals taking
the drug. These changes are known as the digitalis effect
and consist of ST -segment depression with flattening or
inversion of the T wave. The digitalis effect is most
prominent in leads with tall R waves. The digitalis effect is
normal and predictable and does not require
discontinuation of the- drug.
172. The primary pathophysiologic problem in in
idiopathic pulmonary fibrosis is believed to be
1. Microorganism mediated activation of pulmonary
neutrophils
2. Immune complex mediated activation of alveolar
macrophages
3. Direct immune complex mediated pulmonary
interstitial damage
4. Primary fibroblast
Ans. 2.
Bronchoalveolar lavage in patients with idiopathic
pulmonary fibrosis, a chronic inflammatory disorder of the
lower respiratory tract characterized by dyspnea and
reticulonodular infiltrates on chest radiography, discloses
an abundance of alveolar macrophages. Probably related
to locally generated immune complexes, alveolar macro
phages become activated and then produce several
mediators that recruit and induce fibroblast proliferation,
which causes secondary damage. Macrophage-derived
mediators believed to be important in this process include
fibronectin, a 200-kDa dimeric glycoprotein that interacts
with connective tissue matrix as well as specific receptors
on fibroblasts, and platelet-derived growth factor, whose
chain is encoded by the c-sis protooncogene. Platelet-
derived growth factor is believed to play an important role
in recruiting fibroblasts to the site of inflammation.
Macrophages also producechemotaxins such, as
leukotriene 84 and interleukin 8, which attract neutrophils
and eosinophils into the region.
173. Which of the following would be the most
reasonable step in the assessment of the patient of
emphysema due to alpha 1 ATD.
1. Acid starch gel
2. Measurement of sweat chloride concentration
3. High resolution CT scan
4. Exercise stress test
Ans. 1.
To establish baseline information in persons who have
emphysema, spirometry should be performed, and for
persons with significant complaints or physical findings,
arterial blood gases also should be checked. Although
cigarette smoking accounts for the vast majority of cases of
emphysema, a small percentage of persons who develop
this illness have had no exposure to tobacco products. A
subset of this nonsmoking, emphysematous population is
deficient in 1-antitrvpsin. which is a protease inhibitor
that normally is found in the serum. It is currently believed
that release of proteolytic enzymes from inflammatory
cells accounts for the lung destruction that typifies
emphysema, and (Xl-antitrypsin deficiency, a familial
disorder, the genotype of which is acid starch gel and
immunoelectrophoresis, permits this destruction to occur
unimpeded. Exercise testing is not necessary as an initial
screening test for emphysema but should be considered
before oxygen therapy is prescribed. A male who has
emphysematous respiratory failure, gives no history of
respiratory infections, and has children would not have
cystic fibrosis (affected men are sterile); therefore, a sweat
chloride test would not be a useful procedure. High-
resolution CT scan would unlikely add any significant
alteration to the differential diagnosis, and both an
exercise stress test as well as an echocardiogram are not
necessary in the evaluation of this patient.
174. Which of the following statements about
polycystic kidney disease is true
1. Polycystic kidney disease is n autosomal recessive
disorder linked to a causative gene on the short arm of
chromosome 16
2. Erythropoietin levels are often low due to progressive
renal failure.
3. Colonic diverticular disorder is a rare finding
4. Nephrotic range proteinuria is an uncommon finding
Ans. 4.
Autosomal dominant polycystic kidney disease is one of
the most common hereditary disorders. Spontaneous
mutations occur but account for only 10% or fewer of all
cases. The majority of cases are linked to a causative gene
located on the short arm of chromosome 16, referred to as
ADPKD1. A second causative gene (ADPKD2) has not been
identified but seems to be at a locus distinct from ADPKDI,
which appears to be the cause of the gene in -90% of
families in the white population.
A rare syndrome known as autosomal recessive polycystic
kidney disease affects between 1 in 10,000 and 1 in 40,000
individuals in the United States, and the causative gene has
been localized to chromosome. Patients are typically
diagnosed during the first year of life, presenting with
bilateral abdominal masses. Death in the neonatal period is
common due to pulmonary hypoplasia.
The most common complication of polycystic kidney
disease is pain secondary to large cystic kidneys; in
addition, most patients are hypertensive. In addition to the
chronic pain, acute pain may represent cystic hemorrhage,
37
infection, or, less commonly, a renal stone. Proteinuria
occurs in about 1/3 of patients but is typically mild, with <
1 g per 24-h collection. The rare patient with nephrotic-
range proteinuria often has superimposed glomerular
disease.
175. Which of the following statements regarding
eosinophilic enteritis is correct?
1. Peripheral blood eosinophilia is rare )
2. It affects only the small intestine
3. The majority of patients have a history of food
allergies or asthma.
4. It may difficult to distinguish from regional enteritis
Ans. 3.
Malabsorption caused by bacterial overgrowth results
from bacterial utilization of ingested vitamins and the
deconjugation of bile salts by bacteria in the proximal
jejunum. Deconjugated bile salts do not form micelles in
the jejunum, and long-chain fatty acids cannot be
absorbed. The bacteria also separate ingested vitamin 812
from intrinsic factor, thus interfering with its absorption
from the ileum. The absorption of simple carbohydrates
generally is not impaired, though complex carbohydrates
may be metabolized by bacteria. Thus, persons with
bacterial overgrowth have steatorrhea, an abnormal
Schilling test (even with the administration of intrinsic
factor), increased metabolism of nonabsorbable
carbohydrates (e.g., lactulose), and increased bacterial
concentrations in jejunal aspirates. Absorption of Dxylose,
a simple carbohydrate, is often normal.
176. As a consequence of severe liver damage, hepatic
amino acid handling is deranged. In this situation,
plasma levels of which of the following are likely to be
lower than normal?
1. Ammonia (NH3)
2. Ammonium (NH+4)
3. Alanine
4. Urea
Ans. 4.
Amino acids (except for the branched-chain amino acids
leucine, isoleucine, and valine) are taken up by the liver via
the portal circulation and are metabolized to urea. Severe
liver damage disrupts normal amino acid metabolism and
is reflected in elevated serum levels of non-branched-chain
amino acids. Since urea cannot be produced, ammonia
cannot be handled. Elevated levels of serum ammonia
certainly playa large role in the development of hepatic
encephalopathy in patients with liver failure and portal
hypertension. Therefore, levels of ammonia and, in the
case of alkylosis, ammonium ion rise at the expense of
urea. Other mechanisms leading to increased blood
ammonia levels include excessive amounts of intestinal
nitrogen (e.g., resulting from bleeding); decreased
intestinal motility allowing greater bacterial deamination
of amino acids; depressed renal function leading to an
increase in blood urea nitrogen and a greater opportunity
for bacterial urease to convert this to ammonia; alkalosis,
which will preferentially lead the NHt /NH3 equilibrium in
favor of ammonia; and portal hypertension, which will
allow ammonia from the gut to bypass hepatic
detoxification.
177. Which statement regarding the renal
involvement associated with SLE is true?
1. Clinically apparent renal disease occurs in 90% of
affected persons
2. Interstitial nephritis is a rare finding on renal biopsy
3. Renal biopsy is not initially necessary in patients with
deteriorating renal function and active urine sediment
4. Renal disease is uncommon in patients with higher
anti-double stranded DNA antibodies
Ans. 3.
Renal disease is clinically evident in about half of persons
with SLE. However, nearly all persons with SLE have some
evidence of renal disease on renal biopsy. Renal disease
associated with SLE includes both glomerulonephritis and
interstitial nephritis. Glomerular disease has been
classified into membranous nephritis and mesangial, focal,
and diffuse glomerulonephritis. Immune-complex
interstitial nephritis occurs most commonly in persons
who have diffuse glomerulonephritis. Urinalysis
performed in persons with active renal disease usually
reveals microscopic hematuria, red cell casts, and
proteinuria; the exception is membranous lupus nephritis,
in which proteinuria is the dominant finding. Drug-
induced lupus rarely leads to renal disease. Anti-dsDNA
antibodies at high titer are associated with severe
nephritis. Renal biopsy is not necessary in SLE patients
whose renal function is rapidly deteriorating when they
have an active sediment. If such patients fail to respond to
the prompt initiation of glucocorticoid therapy demanded
in such a situation, then biopsy should be undertaken.
Patients with mild clinical disease should have a biopsy to
determine if they have active, severe, inflammatory
lesions, which might respond to therapy.
178. Which statement regarding immune complex
disease is correct?
1. Even under normal condition only a small subsets of
immune complexes are removed complexes in the
reticuloendothelial system?
2. Signs and symptoms stem from the deposition of
massive amount of immune complexes in the
reticuloendothelial system
3. Persistence of immune complexes in the circulation
seems to be a requirement for the development of
renal manifestations
4. Renal lesions depend on antigen-antibody
combinations in which antibody is in slight
excess
Ans. 3.
Most antigen-antibody complexes are cleared by cells of
the reticuloendothelial system. It appears that in some
38
conditions the reticuloendothelial system can be
overwhelmed by immune complexes, thereby impeding
the removal and leading to the deposition of immune
complexes. Deposition of these complexes in tissues other
than those of the reticuloendothelial system is responsible
for the signs and symptoms of immune-complex disease. In
animal models, the persistence of complexes is necessary
for the development of renal disease; also, slight antigen
excess has been found to predispose to the formation of
antigen-antibody complexes, which persist in the
circulation and lead to inflammatory illness. Immune
complex-mediated vascular damage can lead to cutaneous
necrotizing vasculitis. Electron microscopy reveals
subendothelial immune complexes that presumably incite
an array of inflammatory cells to migrate toward the
vessel.
179. Peripheral nerve regenerates at a rate of
1. 0.2 mm/day
2. 1 mm/day
3. 2 mm/day
4. 0.5 nun/day
Ans. 2.
The axonal regeneration proceeds slowly at rate of 1-2
mm/day in human.
180. Km value is defined as -
1. Substrate concentration at Vmax/2
2. Substrate concentration of twice Vmax
3. Substrate concentration of twice Vmax
4. Substrate concentration of one third Vmax
Ans. is 1' i.e., Substrate concentration at Vmax/2
Km is a special rate constant called Michaelis-Menten
constant.
It is a defined as the substrate concentration at which
the reaction rate is half the maximum6.
At this instance the enzyme is half -saturated with its
substrate,
Km reflects binding affinity of the enzyme for its
substrate.
If affinity is more, less substrate is required to saturate
the enzyme, so that Vmax is reached at relatevely low
substrate concentration.
Consequently, the substrate concentration
corresponding to the half V max (i.e., Km) is relatively
low.
For this reason, high-enzyme substrate affinity implies
a low Km value, and conversely, low affinity implies
high Km.
For example, higher Km of glucose for glucokinase
than that for hexokinase indicates that hexokinase
binds glucose with higher affinity than glucokinase.
181. Primer function is in -
1. Transcription
2. Translation
3. Initiation of DNA replication
4. Termination of DNA replication Chromosomes are arranged in pairs and decreasing
order of length.
Ans. is 3 i.e.. Initiation of DNA replication Staining
DNA synthesis cannot commence with Staining allows identification of each individual
deoxyribonuclcotides because DNA polymerase chromosome on the basis of distinctive and reliable
cannot add a mononucleotide to another pattern of alternating light and dark bands. One of the
mononucleotide. following banding techniques may be used.
Thus, DNA polymerase cannot initiate synthesis of
complementary DNA synthesis strand of DNA on a 183. During staining for Electron Microscopy, the
totally single stranded template. method which improves contrast of specimen is
For this, they require RNA primer, which is a short 1. Positive staining
piece of RNA formed by enzyme primase (RNA 2. Negative staining
polymerase6) using DNA as a template. 3. Shadow staining
RNA primer is then extended by addition of 4. None of these
deoxyribonucleotides. Later on, the ribonucleotides of
the primer are replaced by deoxyribonucleotides. Ans. 2. Negative staining.
The specimen stained with phosphotungstic acid in
182. Chromosomal study is best carried out in - electron microscope for better visualisation of the
1. Prophase structures. Negative staining with phosphotungstic acid
2. Metaphase used in electron microscope.
3. Telophase
4. Anaphase
184. The immunoglobulin mediates ADCC
Ans. is '2' i.e., Metaphase 1. IgM
Karyotyping 2. IgA
It is the study of chromosomes. 3. IgG
It is used in cytogenetics to study the chromosomal 4. IgE
abnormalities.
A karyotype is a standard arrangement of a Ans. 3. IgG
photographed or imaged stained metaphase spread in IgG Antibody
which chromosomepairs arc arranged in order of o Half life(23d),
decreasing length. o High Serum concerntration (GAMDE) ,
To produce a karyotype, one must obtain cells capable
of growth and division as karyotyping is done by Responsible for-
arrestingmitosis in dividing cells in metaphase. o Precipitation,
Samples used are o neutralization,
Amniotic fluids (cells from amnion, skin, o NK cell (ADCC)
urogenital system, respiratory system and GI o Classical complement
system). Appear late, indicates past / chronic infection
Chorionic vill.
Bone marrow 185. The immunity responsible for to control epidemic
Skin fibroblasts spread of a pathogen
Peripheral blood lymphocytes 1. Innate immunity
Fetal umblicai blood. 2. Active acquired immunity
Lymph node tissue 3. Herd immunity
Solid tumor sample 4. Passive natural immunity
Method of karyotyping
Dividing cells are arrested in metaphase by addition of Ans. 3. Herd immunity
colchicine or colcemid (deacetylmethylcolchicine). Herd immunity-
Subsequently, cells are exposed to a hypotonic Overall immunity of a community to a pathogen
solution to induce swelling of the cell for enhancing If Herd immunity is good- chance of epidemic is less
spreading of the chromosomes. Eradication of a communicable disease- depends on
The metaphase cells are then fixed with good Herd immunity
methanol/glacial acetic acid mixture and stained by Provided by mass vaccination by live vaccination to all
one of the several banding techniques. individual at same time.
After staining chromosomes are analysed under a
microscope and photographed. 186. Streptolysin O is inactivated by
Finally, a karyotype is constructed by manual or 1. CO2
automated pattern, 2. Nitrogen
39
3. Oxygen 190. Bacillary angiomatosis is caused by
4. Serum 1. Bartonella henselae
2. Hansens bacillus
Ans. 3. Oxygen 3. Kochs bacillus
Streptococci produce 2 types of Streptolysin ( O&S) based 4. H. ducreyi
on oxygen dependency. Streptolysin O is oxygen labile. It is
inactive in the presence of Oxygen. Streptolysin O is Ans. 1. Bartonella henselae
antigenic and ASO titre is a standard serological diagnosis Henselae causes bacillary angiomatosis, a condition
of Acute Rheumatic fever. Streptolysin O & S both can resembling Kaposis sarcoma in patients with AIDS. The
cause hemolysis. skin, lymph nodes or liver and spleen are primarily
involved in this condition. The bacteria also cause sub
187. Weil-Felix reaction with OXK antigen indicates acute bacterial endocarditis.
infection with
1. R. tsustsugamushi 191. The RNA virus which is inhibited by Actinomycin
2. R. mooseri D
3. R. quintana 1. Measles
4. R. akari 2. Polio
3. Influenza
Ans. 1. R. tsustsugamushi 4. Rubella
Weil-Felix reaction:
Serological diagnosis of Rickessial infection. Weil-Felix Ans. 3. Influenza
reaction is a Heterophile agglutination test. Antigens used INFLUENZA VIRUS
are Nonmotile strains of Proteus vulgaris (OX 19, OX 2), Orthomyxovirus, ss negative sense RNA
Proteus mirabilis (OX K). Possesses RNA dependent RNA polymerase
Mechanism: Proteus and Rickessiae will share alkali stable Haemagglutination is the characteristic of influenza virus
carbohydrate antigen will be basis of the Weil-Felix After some time haemagglutination is reversed by
reaction. Weil-Felix is a tube agglutination test. It is a neuraminidase(receptor destroying enzyme also present
simple and useful test for the diagnosis. The Antibody rises V.cholerae) by a process called elution
in 2nd week of illness and reaches the peak and get decline Antigenic variation is common ( Antigenic shift, Antigenic
rapidly during the course of convalescence. drift)
Actinomycin D inhibits multiplication
188. Nichol's strain is used in:
1. TP HA test 192. Relative risk is calculated in?
2. TPI test 1. Cross sectional study
3. VDRL 2. Cohort study
4. FTA-ABS 3. Case cuntiol study
4. None
Ans. 2. TPI test
Treponema pallidum immobilization (TPI) test, considered Ans. is '2' i.e.. Cohort study
both as a qualitative and as a quantitative test, and then Characteristic Cohort Case control Cross
various specific aspects of passage of the Nichols strain of s Study Study Sectional
treponeme in rabbit testes. a serological test for syphilis in Study
which a solution containing the living causative spirochete Design Prospective Retrospectiv One point
(Treponema pallidum) is combined with serum in the e in time
presence of complement with immobilization of the active Incidence Estimated Not Not
spirochetes indicating a positive result estimated estimated
Prevalence Not Not Estimate
189. Inclusion bodies of trachoma are stained with? estimated estimated d
1. Wrights stain Calculations o Incidence Odds ratio
2. Iodine rates
3. Saffranin o Relative
4. Alcian blue risk
o
Ans. 2. Iodine Attributabl
Stained with dilute Lugols iodine solution, some of the e risk
inclusions of C trachomatis appear brown because of the
glycogen matrix that surrounds the particles. Inclusions of
C psittaci are diffuse intracytoplasmic aggregates. 193. ICD chapter 21 includes all except
1. Alcohol

40
2. Tobacco 4. Per capita income
3. Injury
4. Drugs Ans. is 1' i.e., IMR
Subjective component of well being Quality of life
Ans. is 3' i.e., Injury While "level of living" is an objective component,
ICD -10 code in chaptor XXI (Factor influencing health "quality of life" comprises the individual's own
status and contact with health services) : - subjective evaluation.
i) Problem relating to lifestyle The index for quality of life is "Physical quality of life
ii) Alcohol use index (PQLI) 99.
iii) Tobacoo use The PQLI is an attemt to measure quality of life or
iv) Drug use well-being of a country,
v) Lack of physical exercise Physical quality of life index consolidates three
vi) Inappropriate diet and eating habits indicators :-
vii) High risk sexual behaviour i) Literacy rate
ii) Infant mortality rate
194. Vitamin D is maximum in iii) Life expectancy at age 1 year (LE)
1. Milk PQLI ranges from 0 to 100
2. Fish fat PQLI in India is 65.
3. Eggs
4. Cod liver oil 197. Cataract in diabetes
1. Snowflake
Ans. Is '4' i.e., Cod liver oil 2. Sunflower
Vitamin D is found only in food of animal origin (also 3. Nuclear cataract
vit B12). 4. Oil drop
Dietary sources of vitamin D in decreasing order -
1. Halibut liver oil 5. Egg Ans. is '1' i.e., Snowflake
2 Cod liver oil 6. Butter Diabetic cataract
3. Shark liver oil 7. Milk Cataract is considered as a major cause of visual
4. Fish fat impairment in diabetic patients. Senile cataract tends
to develop atan earlier age and more rapidly than
usual in diabetic patients.
195. Iron is maximum in - The enzyme aldolase reductase catalyzes the
1. Pista reduction of glucose to sorbitol through the polyol
2. Cashewnut pathway, aprocess linked to the development of
3. Meat diabetic cataract NADPH* dependent aldolase
4. Milk reductase reducesexcessive glucose to sorbitol and
intracellular accumulation of sorbitol leads to osmotic
Ans. is 3. i.e., Meat changes resulting inhydropic lens fibers that
"Red meat is the richest source of iron "- Artcle degenerate and form sugar cataract.
"Iron content of milk is low in all mammalion speies - Park The typical diabetic cataract is snowflake cataract, i.e.,
Source of iron dense white subcapsular opacities in the anterior and
There are two major forms of iron. posterior cortex resembling a snowstorm.
1. Haem-iron As blood- sugar levels fluctuate, visual acuity and
Better absorbed refractive error can change Fluctating refractive
Less important source of iron in Indian diet. error. This causes frequent change in optimal eyeglass
Sources are Liver, meat9poulty and fish (foods prescription.
of animal origin).
2. Non-haem iron
Poorly absorbed but is the important source of 198. Amaurosisfugax is due to -
iron in the diet of a large majority of Indian 1. TIA
people. 2. Tobacco
Sources are Vegetable origin, Le, cereals, green 3. Optic neuritis
leafy vegetables, Leugumes, nuts, oilseeds, jaggery 4. Papilloedema
and dried fruits.
Ans. is 1 i.e., TIA
196. PQLI includes - Amaurosis fugax is sudden temporary and painless
1. IMR loss of vison due to transient failure of retinal
2. Life expectancy at birth circulation.
3. MMR It may occur in carotid transient ischemic attack (TIA).
41
Amaurosis 4. Keratitis associated with diseases of skin and mucous
Amaurosis is complete loss of sight in one or both membrane.
eyes, in the absence of ophthalmoscopic or other 5. Keratitis associated with systemic collagen vascular
marked objective signs. disorders.
Amaurosis fugax 6. Traumatic keratitis, which may be due to mechanical
It refers to sudden, temporary and painless monocular trauma, chemical trauma, thermal burns, radiations.
visual loss occurring due to a transient failure of 7. Idiopathic keratitis e.g.,
retinal circulation. Common causes are :- a) Mooren's corneal ulcer
Carotid transient ischaemic attacks (TIA) b) Superior limbic keratoconjunctivitis
Embolization of retinal circulation c) Superficial punctate keratitis of Thygeson
Papilledema
Giant cell arteritis 200. Blind areas of the larynx when visualized through
Raynaud's disease Video Laryngoscopy are:
Migraine 1. Ventricle
As a prodromal symptom of central retinal artery 2. Subglottis
or carotid artery occlusion 3. Post Cricoid region
Hypertensive retinopathy 4. Lingual surface of epiglottis
Venous stasis retinopathy
Typically described by the patients as a curtain that Ans. 1. Ventricle
descends from above or ascends from below to occupy
the upper or lower halves of their visual fields. The
attack lasts for two to five minutes and resolves in the
reverse pattern of progression, leaving no residual
deficit.
Uraemic amaurosis
It is sudden, bilateral, complete loss of sight occuring
probably due to the effect of certain toxic materials
upon the cells of the visual centre in patients suffering
from acute nephritis, eclampsia of pregnancy and
renal failure.It is associated with dilated pupils which
generally react to light. Usually, the vision recovers in
12-48 hours.

201. Lymphatic Drainage of the Maxillary Sinus goes

199. Keratitis is caused by first to
1. Bacteria 1. Upper Deep Cervical Lymph Nodes
2. Atopy 2. Submental Nodes
3. Protozoa 3. Submandibular Nodes
4. All 4. Retropharyngeal Nodes

Ans. is '4' i.e., All Ans. 4. Retropharyngeal nodes

Causes of keratitis Through the posterior pathway, the lymphatics from the
1. Infective keratitis maxillary and ethmoid sinuses drain into the
a) Bacterial retropharyngeal lymph nodes
b) Viral
c) Fungal 202. Blood supply of the tonsil is all except:
d) Chlamydial 1. Ascending pharyngeal Artery
e) Protozoal 2. Sphenopalatine artery
f) Spirochactal 3. Facial artery
2. Allergic keratitis 4. Descending palatine artery
a) Phlyctenular keratitis
b) Vernal keratitis Ans. 2. Sphenopalatine artery
c) Atopic keratitis
3. Trophic keratitis
a) Exposure keratitis
b) Neuroparalytic keratitis
c) Keratomalacia
d) Atheromatous ulcer

42
 2. First pass is to examine middle meatus
3. Second pass is to examine the superior meatus
4. Third pass is the examine the inferior meatus

Ans. 3. Second pass is to examine superior meatus

All other options are wrong the right answers are:
There are three passes
First is along inferior meatus
Second is to inspect superior meatus and
sphenoethmoid recess
Third is to inspect the middle meatus

205. Most common major salivary gland malignancy is:

1. Mucoepidermoid carcinoma
2. Pleomorphic adenoma
3. Adenoid cystic carcinoma
4. Adenocarcinoma

203. All are mechanisms of bone conduction except: Ans. 1. Mucoepidermoid carcinoma, Pg 2497 Scott
1. Vibrations of air column of the EAC Brown Otorhinolaryngology Vol2
2. Vibrational inertia of ossicles
3. Vibration of the inner ear 206. Plunging ranula refers to a mucocoele that has
4. Air conduction through the Tympanic Membrane penetrated which muscle?
1. Sternohyoid
Ans. 4. Air conduction through the tympanic 2. Stylohyoid
membrane 3. Omohyoid
This is a method of air conduction, the other 3 are the 4. Mylohyoid
mechanisms of bone conduction
Ans. 4. Mylohyoid

207. All are contents of the middle ear except:

1. Stapedius
2. Tensor tympani
3. Facial nerve
4. Chorda tympani

Ans. 3. Facial Nerve

All the other structures with the tympanic plexus is

described as contents of the middle ear cavity
The facial nerve is described as a part of the medial
and posterior wall of the tympanic cavity

204. True about Nasal Endoscopy is:

1. There are 4 passes

43

208. True about Ackermans tumor Is
1. It is a highly malignant tumor
2. Verrucous carcinoma of the larynx
3. Radiotherapy is the treatment of choice
4. Spreads via lymphatics in early stage itself
Ans. 2. Verrucous carcinoma of the larynx
It is a low grade locally aggressive malignancy. Well
differentiated squaumous cell carcinoma with very
low metastasis rate.
Radiotherapy is contraindicated as it can produce
anaplastic change.
209. Most common cause of Chronic Retropharyngeal
abscess in adults in India is:
1. HIV
2. Impacted foreign Body
3. Complication of tonsillitis
4. Tuberculosis
Ans. 4. Tuberculosis Medscape
All other causes produce acute symptoms and in India
Tuberculosis is still a very orevalent disease.
210. Brodie's abscess is -
1. Acute osteomyelitis
2. Subacute osteomyelitis
3. Chronic osteomyelitis
4. Septic arthritis
Ans. is 3 i.e., Chronic osteomyelitis
Brodie's abscess Chronic osteomyelitis
44
Garre's sclerosing osteomyelitis Chronic
osteomyelitisor subacute form of chronic osteomyelitis
"Brodie's abscess is a chronic localized hone abscess"
Postgraduate orthopaedics
"Brodie s disease is a localized form of chronic
osteomyelitis " Ebnezar
Brodie's abscess
Brodie's abscess is a special form of chronic
osteomyelitis which arises insidously, without a
preceding acute attack.
There is localized abscess within the bone, often near
the site of the metaphysis of long hones.
Common sites are upper end of the tibia and lower end
of the femur.
A deep 'boring* pain is the predominant symptom.
Pain may become worse at night. Radiographically, the
lesion is seen as a circular or oval cavity surrounded
by a zone of sclerosis,
Treatment is by operation.
Surgical evacuation and curretage is performed with
or without bone grafting.
There are three types of chronic
osteomyelitis:
a) Chronic osteomyelitis secondary to acute
osteomyelitis.
b) Garres osteomyelitis.
c) Brodies abscess.
211. Malignancies associated with BRCA 1 and 2
includes all except
1. Breast cancer
2. Prostate cancer
3. Papillary serous carcinoma of peritoneum
4. Mesothelioma
Ans. 4
212. The investigative method of choice for
confirmation of H.pylori eradication is
1. Urea breath test
2. Rapid urease assay
3. Culture from gastric mucosa
4. Serology
Ans. 1
In summary, it is not necessary to perform endoscopy to
diagnose H. pylori. Serology is the test of choice for initial
diagnosis when endoscopy is not required. If, however,
endoscopy is to be performed, the rapid urease assay and
histology are both excellent options, but the cost
advantage lies with the rapid urease assay. After
treatment, the urea breath test is the method of choice but
again should not be performed until 4 weeks after therapy
ends. If the breath test is unavailable, endoscopy may be
performed in selected patients such as those with bleeding
ulcers or other complications of their PUD.
213. Splenic auto infarction is seen in
1. Splenic amyloidosis
2. Thalassemia
3. Sickle cell disease
4. Gauchers disease
Ans: 3
Sickle cell disease
As the largest unit of the mononuclear phagocyte system,
the spleen is involved in all systemic inflammations,
generalized hematopoietic disorders, and many metabolic
disturbances. In each, the spleen undergoes enlargement
(splenomegaly), which is the major manifestation of
disorders of this organ. It is rarely the primary site of
disease. Splenic insufficiency due to splenectomy or
autoinfarction (as in sickle-cell disease) has one major
clinical manifestation, an increased susceptibility to sepsis
cause by encapsulated bacteria such as pneumococcus,
meningococcus, and Haemophilus influenzae. The loss of
filtering and antibody production functions both
contribute to the increased risk of sepsis, which may be
fatal. All asplenic individuals should be vaccinated against
these agents to reduce the risk of this tragic complication.
214. All are false of Brutons Agammaglobulinemic
except
1. It is X linked
2. T cell abnormality seen
3. Seen only in males
4. Increase in number of plasma cells
Ans: 1
It is X linked
X-linked agammaglobulinemia is one of the more common
forms of primary immunodeficiency. It is characterized by
the failure of B-cell precursors (pro-B cells and pre-B cells)
to develop into mature B cells. As an X-linked disease, this
disorder is seen almost entirely in males, but sporadic
cases have been described in females, possibly caused by
mutations in some other gene that functions in the same
pathway. The disease usually does not become apparent
until about 6 months of age, as maternal immunoglobulins
are depleted.
The classic form of this disease has the following
characteristics:
B cells are absent or markedly decreased in the
circulation, and the serum levels of all classes of
immunoglobulins are depressed. Pre-B cells, which
express the B-lineage marker CD19 but not membrane Ig,
are found in normal numbers in the bone marrow.
Germinal centers of lymph nodes, Peyer's patches, the
appendix, and tonsils are underdeveloped.
Plasma cells are absent throughout the body.
T cellmediated reactions are normal.
45
215. The definite diagnosis of malignancy in
pheochromocytoma is based on
1. Presence of metastasis
2. Cellular pleomorphism
3. Nuclear pleomorphism
4. Mitotic figures
Ans: 1
presence of metastasis
Pheochromocytoma are neoplasms composed of
chromaffin cells, which synthesize and release
catecholamines and in some instances peptide hormones.
It is important to recognize these tumors because they are
a rare cause of surgically correctable hypertension.
Pheochromocytoma range from small, circumscribed
lesions confined to the adrenal to large hemorrhagic
masses weighing kilograms. The tumors are composed of
polygonal to spindle-shaped chromaffin cells or chief cells,
clustered with the sustentacular cells into small nests or
alveoli (zellballen) by a rich vascular network. The
cytoplasm has a finely granular appearance, best
demonstrated with silver stains, due to the presence of
granules containing catecholamines. The nuclei are usually
round to ovoid, with a stippled salt and pepper
chromatin that is characteristic of neuroendocrine tumors.
There is no histologic feature that reliably predicts
clinical behavior. Several histologic features, such as
numbers of mitoses, confluent tumor necrosis, and spindle
cell morphology, have been associated with an aggressive
behavior and increased risk of metastasis, but these are
not entirely reliable. Tumors with benign histologic
features may metastasize, while bizarrely pleomorphic
tumors may remain confined to the adrenal gland. In fact,
cellular and nuclear pleomorphism, including the presence
of giant cells, and mitotic figures are often seen in benign
pheochromocytomas, while cellular monotony is
paradoxically associated with an aggressive behavior. Even
capsular and vascular invasion may be encountered in
benign lesions. Therefore, the definitive diagnosis of
malignancy in pheochromocytomas is based exclusively on
the presence of metastases. These may involve regional
lymph nodes as well as more distant sites, including liver,
lung, and bone.
216. All are true about primary CNS lymphoma except
1. Most primary brain lymphomas are of B-cell origin.
2. Anaplastic large cell lymphomas are the most common
histologic group.
3. Hooping is characteristic of primary brain lymphoma.
4. Primary lymphomas of the CNS are aggressive
Ans: 2
Anaplastic large cell lymphomas are the most common
histologic group
Primary CNS lymphoma accounts for 2% of extra-nodal
lymphomas and 1% of intra-cranial tumors. It is the most
common CNS neoplasm in immunosuppressed individuals,
including those with AIDS and immunosuppression after
transplantation. Most primary brain lymphomas are of B-
cell origin. In the setting of immunosuppression, the cells
in nearly all such tumors are latently infected by Epstein-
Barr virus. Overall, primary lymphomas of the CNS are
aggressive, with relatively poor response to chemotherapy
compared with peripheral lymphomas. Diffuse large-cell B-
cell lymphomas are the most common histologic group.
Within the tumor malignant cells infiltrate the parenchyma
of the brain and accumulate around blood vessels.
Reticulin stains demonstrate that the infiltrating cells are
separated from one another by silver-staining material;
this pattern, referred to as hooping, is characteristic of
primary brain lymphoma.
217. Durck granuloma is seen in
1. Tuberculosis
2. Leprosy
3. Actinomycosis
4. Malaria
Ans: 4. Malaria
In malignant cerebral malaria caused by P. falciparum,
brain vessels are plugged with parasitized red cells.
Around the vessels there are ring hemorrhages that are
probably related to local hypoxia incident to the vascular
stasis and small focal inflammatory reactions (called
malarial or Durck granulomas). With more severe hypoxia,
there is degeneration of neurons, focal ischemic softening,
and occasionally scant inflammatory infiltrates in the
meninges.
218. All are true of Verner Morrison syndrome (WDHA
syndrome) except
1. It is associated with Vipoma
2. Presents with secretory diarrhea
3. Can be associated with ganglioneuroblastoma
4. Associated with hyperkalemia
Ans: 4
Associated with hyperkalemia
VIPoma (watery diarrhea, hypokalemia, achlorhydria, or
WDHA syndrome) is an endocrine tumor of pancreas that
induces a characteristic syndrome, caused by release of
vasoactive intestinal peptide (VIP) from the tumor. Some
of these tumors are locally invasive and metastatic. A VIP
assay should be performed on all patients with severe
secretory diarrhea. Neural crest tumors, such as neuro
blastomas, ganglioneuroblastoma, and ganglioneuromas
and pheochromocytoma can also be associated with the
Vipoma syndrome.
219. All are true of Benign nephrosclerosis except
1. Kidneys are small with fine granularity
2. Histological examination revealed hyaline
arteriolosclerosis
3. Hyperplastic arteriolitis
4. Fibroelastic hyperplasia is seen
Ans: 3
46
Hyperplastic arteriolitis
Benign nephrosclerosis is the term used for the renal
pathology associated with sclerosis of renal arterioles and
small arteries. The resultant effect is focal ischemia of
parenchyma supplied by vessels with thickened walls and
consequent narrowed lumens. The parenchymal effects
include glomerulosclerosis and chronic tubulointersititial
injury, producing a reduction in functional renal mass. The
kidneys are either normal or moderately reduced in size.
The cortical surfaces have a fine, even granularity that
resembles grain leather. The loss of mass is due mainly to
cortical scarring and shrinking. On histologic examination
there is narrowing of the lumens of arterioles and small
arteries, caused by thickening and hyalinization of the
walls (hyaline arteriolosclerosis). Corresponding to the
fine surface granulations are microscopic subcapsular
scars with sclerotic glomeruli and tubular dropout,
alternating with better preserved parenchyma. In addition,
the interlobular and arcuate arteries show a characteristic
lesion that consists of medial hypertrophy, reduplication of
the elastic lamina, and increased myofibroblastic tissue in
the intima, which combine to narrow the lumen. This
change, called fibroelastic hyperplasia, often accompanies
hyaline arteriolosclerosis and increases in severity with
age and in the presence of hypertension.
220. The following are true about acanthosis nigrans
except
1. It is an important cutaneous marker of benign
conditions
2. It is autosomal recessive
3. It is an important cutaneous marker of malignant
conditions
4. Most commonly appears in the flexural areas of the
body
Ans: 2
It is autosomal recessive
Acanthosis nigricans is a condition marked by thickened,
hyperpigmented skin with a velvet-like texture that most
commonly appears in the flexural areas (axillae, skin folds
of the neck, groin, and anogenital regions). It can be an
important cutaneous marker of benign and malignant
conditions and, accordingly, is divided into two types. The
benign type, which constitutes about 80% of all cases,
develops gradually and usually occurs in childhood or
during puberty. It may occur (1) as an autosomal dominant
trait with variable penetrance, (2) in association with
obesity or endocrine abnormalities (particularly with
pituitary or pineal tumors and diabetes), and (3) as part of
several rare congenital syndromes. As with seborrheic
keratoses, acanthosis nigricans sometimes occurs as a
paraneoplastic process resulting from the production of
growth factors by a variety of tumors. The malignant type
refers to lesions arising in middle-aged and older
individuals in association with underlying cancers, most
commonly gastrointestinal adenocarcinomas. The
epidermis and underlying enlarged dermal papillae
undulate sharply to form numerous repeating peaks and
valleys. Variable hyperplasia may be seen, along with
hyperkeratosis and slight basal cell layer
hyperpigmentation (but no melanocytic hyperplasia). The
familial form is associated with germline activating
mutations in FGFR3; depending on the mutation,
acanthosis may be an isolated finding or be seen together
with skeletal deformities, including achondroplasia and
thanatophoric dysplasia.
221. The only reliable means of diagnosing acute
cardiac rejection before substantial myocardial
damage has occurred is
1. Echocardiography
2. ECG
3. Endomyocardial biopsy
4. Ultrasound
Ans: 3
Endomyocardial biopsy
Ans: Of the major complications, allograft rejection is the
primary problem requiring surveillance; scheduled
endomyocardial biopsy is the only reliable means of
diagnosing acute cardiac rejection before substantial
myocardial damage has occurred and at a stage that is
reversible in the majority of instances. Rejection is
characterized by interstitial lymphocytic inflammation
that, in its more advanced stages, damages adjacent
myocytes; the histology resembles myocarditis. When
myocardial injury is not extensive, the rejection episode
is usually either self-limited or successfully reversed by
increased immunosuppressive therapy. Advanced
rejection may be irreversible and fatal if it is not promptly
treated.
222. The most common type of Rhabdomyosarcoma is
1. Embryonal
2. Alveolar
3. Pleomorphic
4. Inflammatory
Ans: 1
Embryonal
Rhabdomyosarcoma, the most common soft-tissue
sarcoma of childhood and adolescence, usually appears
before age 20. It may arise in any anatomic location, but
most occur in the head and neck or genitourinary tract,
where there is little if any skeletal muscle as a normal
constituent. Rhabdomyosarcoma is histologically sub
classified into embryonal, alveolar, and pleomorphic
variants. The rhabdomyoblastthe diagnostic cell in all
typescontains eccentric eosinophilic granular cytoplasm
rich in thick and thin filaments. Rhabdomyoblasts may be
round or elongate; the latter are known as tadpole or strap
cells, and may contain cross-striations visible by light
microscopy.
Embryonal rhabdomyosarcoma is the most common type,
accounting for 60% of rhabdomyosarcomas. It includes the
sarcoma botryoides as well as spindle cell and anaplastic
47
variants. The tumor occurs in children younger than 10
years of age and typically arises in the nasal cavity, orbit,
middle ear, prostate, and paratesticular region. This
variant of rhabdomyosarcoma commonly has parental
isodisomy of chromosome 11p15.5, which leads to
overexpression of the imprinted IGFII gene. The sarcoma
botryoides subtype develops in the walls of hollow,
mucosal-lined structures, such as the nasopharynx,
common bile duct, bladder, and vagina. Where the tumors
abut the mucosa of an organ, they form a submucosal zone
of hypercellularity called the cambium layer.
223. The gold standard for diagnosing the Cystic
fibrosis is
1. Sequencing the CFTR gene
2. Sweat chloride test
3. Positive newborn screening test result
4. Nasal transepithelial potential difference
Ans: 1
Sequencing the CFTR gene
In most cases, the diagnosis of cystic fibrosis is based on
persistently elevated sweat electrolyte concentrations
(often the mother makes the diagnosis by recognizing her
infant's abnormally salty sweat), characteristic clinical
findings (sinopulmonary disease and gastrointestinal
manifestations), an abnormal newborn screening test, or a
family history. A minority of patients with cystic fibrosis,
especially those with at least one mild CFTR mutation,
may have a normal or near-normal sweat test (<60 mM/L).
Measurement of nasal transepithelial potential difference
in vivo can be a useful adjunct test under these
circumstances; individuals with cystic fibrosis
demonstrate a significantly more negative baseline nasal
potential difference than controls. Sequencing the CFTR
gene is, of course, the gold standard for diagnosis of
cystic fibrosis. Therefore, in patients with suggestive
clinical findings or family history (or both), genetic
analysis may be warranted.
224. The origin of Klatskin tumors is from
1. Liver
2. Gall bladder
3. Confluence of cystic duct and hepatic duct
4. Confluence of right and left hepatic ducts
Ans: 4. Confluence of right and left hepatic ducts
The tumours arising at the confluence of right and left
hepatic ducts at the liver hilus are called Klatskin tumours.
These tumours are notable for their slow growing
behaviour, marked sclerosing characteristics, and
infrequent occurrence of distal metastasis.
225. Flame cells are seen in
1. Multiple myeloma
2. Malignant melanoma
3. Nodular colloid goiter
4. Hashimoto thyroiditis

Ans: 1. Multiple myeloma
Multiple myeloma usually presents as destructive plasma
cell tumors (plasmacytomas) involving the axial skeleton.
Relatively normal-appearing plasma cells, plasma blasts
with vesicular nuclear chromatin and a prominent single
nucleolus, or bizarre, multinucleated cells may
predominate. Other cytologic variants stem from the
dysregulated synthesis and secretion of Ig, which often
leads to intracellular accumulation of intact or partially
degraded protein. Such variants include flame cells with
fiery red cytoplasm, Mott cells with multiple grapelike
cytoplasmic droplets, and cells containing a variety of
other inclusions, including fibrils, crystalline rods, and
globules. The globular inclusions are referred to as Russell
bodies (if cytoplasmic) or Dutcher bodies (if nuclear). In
advanced disease, plasma cell infiltrates may be present in
the spleen, liver, kidneys, lungs, lymph nodes, and other
soft tissues.
226. Szary-Lutzner cells are seen in
1. ALCL
2. Hairy cell leukemia
3. Mycosis fungoides
4. PTCL
Ans: 3. Mycosis fungoides
Cutaneous T cell lymphoma (CTCL) represents a spectrum
of lymphoproliferative disorders affecting the skin. Two
different clinical types of malignant T-cell disorders were
originally recognized: mycosis fungoides, a chronic
proliferative process; and a more aggressive nodular
eruptive variant, mycosis fungoides d'emble. Lesions of
mycosis fungoides usually involve truncal areas and
include scaly, red-brown patches; raised, scaling plaques
that may even be confused with psoriasis; and fungating
nodules. In some individuals, seeding of the blood by
malignant T cells is accompanied by diffuse erythema and
scaling of the entire body surface (erythroderma), a
condition known as Szary syndrome. The histologic
hallmark of CTCL of the mycosis fungoides type is the
presence of the Szary-Lutzner cells. These are T-helper
cells (CD4+) that characteristically form band-like
aggregates within the superficial dermis ( Fig. 25-19B )
and invade the epidermis as single cells and small clusters
(Pautrier microabscesses). These cells have markedly in
folded nuclear membranes, imparting a hyperconvoluted
or cerebriform contour. Although patches and plaques
show pronounced epidermal infiltration by Szary-Lutzner
cells (epidermotropism), in more advanced nodular
lesions the malignant T cells often lose this epidermotropic
tendency, grow deeply into the dermis, and eventually
spread systemically.
227. Mycobacterium avium complex infections are
common when the CD4+ counts in cells/mm3 are
1. 200
2. < 200
3. >50
48
4. < 50
Ans: 4
< 50 cells/ mm3
The CD4+ T-cell count can define the risk of infection with
specific organisms. As a rule of thumb, bacterial and
tubercular infections are more likely at higher CD4+
counts (>200 cells/mm3). Pneumocystis pneumonia
usually strikes at CD4+ counts below 200 cells/mm3, while
cytomegalovirus and Mycobacterium avium complex
infections are uncommon until the very late stages of
immunosuppression (CD4+ counts <50 cells/mm3).
228. 20 year old patient presents with peripheral
neuropathy, ataxia, distal sensory loss and muscle
weakness, hearing loss , and ichthyosis. CSF shows
elevated protein level. The most likely diagnosis is
1. Fabry disease
2. Refsum disease
3. Adrenoleukodystrophy
4. CMT4
Ans. 2
Refsum disease can manifest in infancy to early adulthood
with the classic tetrad of (1) peripheral neuropathy, (2)
retinitis pigmentosa, (3) cerebellar ataxia, and (4) elevated
CSF protein concentration. Most affected individuals
develop progressive distal sensory loss and weakness in
the legs leading to footdrop by their 20s. Subsequently, the
proximal leg and arm muscles may become weak. Patients
may also develop sensorineural hearing loss, cardiac
conduction abnormalities, ichthyosis, and anosmia.
Serum phytanic acid levels are elevated. Sensory and
motor NCS reveal reduced amplitudes, prolonged
latencies, and slowed conduction velocities. Nerve biopsy
demonstrates a loss of myelinated nerve fibers, with
remaining axons often thinly myelinated and associated
with onion bulb formation.
229. 20 year old patient presents with hypokalemia,
alkalosis with normal blood pressure and no edema.
the diagnosis is
1. Bartter syndrome
2. Liddle syndrome
3. Glucocorticoids remediable aldosteronism
4. Apparent mineralocorticoid excess syndrome
Ans. 1
It is characterized by hypokalemia , alkalosis, high rennin
level and hypercalciuria , but with normal blood pressure
and no edema.
This is due to mutation Na-k-cl co transporter gene ,
usually begins in childhood.
230. Combination chemotherapy ( ABV )with
daunorubicin , bleomycin , vincristine is used in
1. Kaposi sarcoma
2. Rhabdomyosarcoma
3. Wilms tumour
4. Seminoma Hormone level in sick euthyroid syndrome usually of
1. Low T3 , nomal T4 , TSH low T3 syndrome
Ans. 1 2. Low T3, low T4 , normal TSH low T4 syndrome- severe
It is used in Kaposis sarcoma. Intraleisional danorubicin cases
and vinblastine, radiation treatment, placitaxel, interferon
alpha are also used. 236. CNS lupus manifestations include all of the
following except
231. Pallas sign seen in 1. Seizures
1. Sarcoidosis 2. Psychosis
2. Emphysema 3. Encephalopathy
3. Pulmonary embolism 4. Hemorrhage
4. Myeloma
Ans. 4.
Ans. 3
Chest radiograph signs in PE are , 237. False regarding Peutz Jeghers syndrome
Pallas sign enlarged right descending pulmonary artery 1. Autosomal recessive
Hamptons hump- wedge shaped density above diaphragm 2. Presence of hamartomatous polyps
Westermark sign- focal oligemia. 3. Presence of cutaneous pigmentation
4. Risk of developing breast, lung , ovarian cancer .
232. Bridge therapy is employed in
1. Mononeuritis multiplex Ans. 1.
2. Rheumatoid arthritis It is a autosomal dominant condition.
3. Osteoarthritis Other options are right.
4. Caplan syndrome
238. Bone marrow aspirate of a patient shows
Ans. 2 homogenous, medium sized neoplastic cells with many
In RA , acute symptoms is controlled with steroids , mitotic figures producing starry sky appearance.
followed by treatment with DMARD. This is called bridge Macrophages with pale cytoplasm are scattered. The
therapy most likely pathological identification
1. Lymphoplasmacytic lymphoma
233. In Glanzmann thrombasthenia, the defect is 2. Burkitt lymphoma
1. Decreased platelets 3. Monocytoid B cell lymphoma
2. Defective adhesion 4. Adult T cell lymphoma
3. Defective aggregation
4. Defective secretion of granules Ans. 2
Given picture describes so called starry sky pattern of
Ans. 3 Burkitt lymphoma.
It is due to defective aggregation because of surface
deficiency of GP II b- IIIa. 239. Usual presentation of cauda equina syndrome is
1. Sudden and unilateral
234. QT prolongation seen in all of the following 2. Gradual and bilateral
conditions except 3. Sudden and bilateral
1. Digitalis toxicity 4. Gradual and unilateral
2. Hypokalemia
3. Hypocalcemia Ans. 4. ref Harrison 17 th ed p no 2589.
4. Jervell syndrome Conus medullaris syndrome is usually sudden and bilateral
whereas cauda equina is grdual and unilateral.
Ans. 1 ,
Short QT interval seen in 240. All of the following are associated with thymoma
1. Digoxin toxicity except
2. Hypercalcemia. 1. Graves disease
2. Polymyositis
235. True regarding sick euthyroid syndrome 3. Hypergammaglobulinemia
1. Normal TSH, T3 , T4 level 4. Pure red cell aplasia.
2. Normal TSH, low T3, normal T4 level
3. High TSH, low T3, low T4 level Ans. 3.
4. High TSH, low T3, high T4 level. It is characterized by , hypogammaglobulinemia not
hypergammaglobulinemia.
Ans. 2.

49
241. Ascorbic acid is required for synthesis of Ans. is 2 i.e., Highly structured cell with organized cell
1. Phenylserine organelles
2. Homeserine Prokaryotesand Eukaryotes
3. Hydeoxylysine All cells fall into one of the two major classification-
4. Selenocysteine 1)Prokaryotes or 2) Eukaryotes
1. Prokaryotes
Ans. is 3 i.e., Hydroxylysine Prokaryotes are evolutionally ancient, i.e. they arc first
Hydroxylation of proline and lysine residue takes living organisms to evolve,
place during post-translational modification in rough They were here first and for billions of years were the
ER. only form of life.
The enzyme catalyzing the reactions are prolyl Prokaryotic cells are not carrying of life processes by
hydroxylase (for proline) and lysyl hydroxylase (for themselves. The reason is that they don V have alt the
lysine), organelles (e.g. nucleus, mitochondria, golgi apparatus
Both these enzymes are dioxygenases using molecular etc.) required to carry out life processes. So, these
oxygen (02) and cofactor for both these enzymes is cells are dependent on other cells in order to form
vitamin what is necessary for the life processes.
C (ascorbic acid). -Ketoglutatrate is a coreductant, Prokaryotes divide by binary fission.
which is oxidized to succinate. Prokaryotes are always single celled except when they
These hydroxylated amino acids arc not reprsented in the exist in colonics.
genetic code (i.e. there is no t-RNA for these^), therefore Examples- bacteria (including chlamydia &
they have to be synthesized post-translationally from mycoplasma). Blue green algaeu, Archea
proline and lysine residue in the polypeptides. 2. Eukarvotes
Eukaryotes are more complex, evolving from a
242. Catalase positive coagulase negative beta prokaryote like precdecessor.
hemolytic bacteria- Eukaryotic cells contain all the organelles required to
1. Strep pyogens earn out the processes oflife.
2. Staph aureus Eukaryotes may be single celled or multicelled.
3. Coagulase negative staph The most noticable feature that differentiates
4. Enterococci eukaryotes from prokaryotes is the presence of
nucleus.
Ans. is 3' i.e., Coagulase negative staph Examples-Fungi, Algae other than blue green algae,
protozoa.
Gram positive cocci
244. Fluidity buffer present in cell membrane is
Catalase test 1. Stearic acid
2. Palmitic acid
(+ve) (-ve) 3. Cholesterol
Staphylococci Streptococci 4. Linoleic acid

Coagulase protein A Ans. 3

(+ve) (-ve)
S. aureus Coagulase negative Membrane fluidity
Staphylococci Membrane fluidity changes with temperature
Transition temperature (Tm)

Novobiocin susceptible

(+ve) (- ve)
S. epidermidis S. saprophytics
S. hemolylicus

243. Eukaryotes are different in causing infection

because-
1. Divide by biniary fission
2. Highly structured cell with organized cell organelles
3. Dont have all organelles
4. Ecolutionally ancient

50
 246. Which part of bacteria is most antigenic-
1. Protein coat
2. Lipopolysaccharide
3. Nucleic acid
4. Lipids

Ans. is '1' i.e., Protein coat

Proteins are most immunogenic, while lipids & nucleic
acids arc least immunogenic.
Polysaccharides (carbohydrates) are less
immunogenic than protein antigens, but are more
antigenic than lipids &nucleic acids.
Determinants of antigenicity
A number of properties of antigen determine its
antigenicity (production of antibody or induction of cell
mediated immunity):
1. Chemical nature
More is the Tm,less is the fluidity
Cholesterol-Fluidity buffer Proteins > Polysaccharide > lipids and nucleic
acids.
Saturated FAs All proteins except gelatin arc immunogenic.
increase Tm and decrease fluidity 2. Size
Unsaturated FAs High molecular weight particles > low molecular
decrease Tm and increase fluidity weight particles.
3. Foreign ness
245. Virus quantification is done by In general, molecules recognized as "self are not
1. Egg inoculation immunogenic; for immunogenicity, molecules
2. Hemadsorption must be recognized as "nonself".
3. Plaque assay 4. Susceptibility to tissue enzymes
4. Electron microscopy Only substances which are metabolized and are
susceptible to the action of tissue enzymes behave
Ans. is 3' i.e., Plaque assay as antigens.
Plaque assay and Pock assay are quantitative infective 5. Route of administration
assays. Parenteral > oral
Viral assays
Virus content of a specimen can be assayed in two ways - 247. Ehrlichia chaffeensis is causative agent of
1- With reference to total virus particles - 1. Human monocytic ehrlichiosis
Electron microscopy 2. Human granulocytic ehrlichiosis
Hemagglutination 3. Glandular fever
2- With reference to the infectious virions only 4. None
A) Quantal Assays
indicates the presence or absence of infectious virus Ans. is 1 i.e., HME
e.g. Ehrlichiae
1. Death of the experimental animal These are gram negative, obligate intracellular
2. Production of heamagglutinin in allantoic fluid bacteria which have affinity towards blood cells,
3. Appearance of cytopathological effects on ceil They grow within phagosomes of phagocytes as
cultures mulberry-like clusters called morula.
B) Quantitative infective assay They are tick-borne.
It measures the exact no. of infectious particles eg. Three human infections caused by this group of
a) Plaque assay on monolayer cell culture organisms have been identified :-
Each infectious viral particle gives rise to a 1. Human monocytic ehrlichiosis (HME)
localized focus of infected cells that can be seen It is caused by E. chaffeensis, and transmitted by
with the naked eye. Such foci are known as Amblyomma ticks.
plaques. Deer and rodents are believed to be reservoir
Each plaque indicates an infectious virus. hosts.
b) Pock Assay on chick embryo CAM (Chorioallantoic There is leukopenia, thrombocytopenia and
membrane) elevated liver enzymes.
Viruses that form pocks on CAM can be assayed by 2) Human granulocytic ehrlichiosis (HGE)
counting the no. of pocks.
51
 It is caused by E. equi (E. phagocytophila), and 3. Campylobacter jejuni.
transmitted by ixodes ticks.
Deer, cattle and sheep are suspected reservoirs. 249. Immunoglobulin changes in variable region-
There is leucopenia and thrombocytopenia. 1. Idiotype
3) Glandular like fever 2. Isotype
It is caused by Ehrlichia sennetsu 3. Allotype
No arthopod vector has been identified and 4. Epitope
infection is caused by ingestion offish carrying
infected flukes. Ans. is 1' i.e., Idiotype
Theres is lymphoid hyperplasia with atypical Variability of amino acid sequences at the variable
lymphocytosis. regions form the specific antigen binding site, i.e.
o Doxycvcline is recommended for treatment of idiotype.
ehrlichiosis. The aminoacid sequences of the variable regions arc
not uniformly variable along their length, but consist
248. Invasive infection caused by all except of relatively invariable and some highly variable
1. Shigella zones. The highly variable zones are involved with the
2. Salmonella formation of antigen binding sites. The sites on the
3. V. Cholerae hyervariable regions that make actual contact with the
4. Yersinia epitopes are called "complementarity determining
regions (CDRs)
Ans. is '3' i.e., V. cholerae "The idiotype is defined as the specific region of the
o Based on the depth of intestinal invasion, there are fab portion of the Ig molecule to which antigen binds".
different clinical manifestations of infection with The infinite range of the antibody specificity of
organisms causing diarrhea; immunoglobulin depends on the variability of the
1. No cell invesion (noninflammatory) aminoacid sequences at the variable regions of the H
o The bacteria bind to intestinal epithelial cells but and L chains which form the antigen combining sites.
do not enter the cell.
o Diarrhea is caused by the release of entcrotoxins. 250. Which part of chlorine disinfection is most
o Watery diarrhea with no fecal leukocytes and no effective?
systemic symptoms (e.g. fever) occurs, 1. Hypochlorous acid
Organisms are: 2. Hypochlorousion
1. V. cholerae 6. Giardia 3. Hypochlorite ion
2. ETEC 7. Cryptosporidia 4. None
3. Staph, aureus 8. Microsporidia
4. Clostridium perfringens 9. Rotavirus Ans. is '1' i.e., Hypochlorous acid
5. B. cereus 10. Adenovirus Chlorination
2. Invasion of the intestinal epithelial cells o Chlorination is one of the greatest advances in water
(Inflammatory) purification.
The organisms have virulence factors that allow o Chlorine kills pathogenic bacteria, but has no effect on
binding and invasion into cells, spores, certain viruses (e.g., polio, viral hepatitis) and
Toxins may be then released that destroy the cell. cyst of E. histolytica, in usual doses.
The cell penetration results in a systemic immune Mechanism of action
response with fecal leukocytes as well as fever, o When chlorine is added to water, there is formation of
The cell death results in RBC leakage into the stool hypochloric and hypochlorous acid
(dysentery). o The hypochloric acid is neutralized by the alkanity of
Organisms are: the water.
1. Shigella 6. Yersinia enterocolitica o The hypochlorous acid ionizes to form hydrogen ions
2. Salmonella Sp. 7. C. difficale and hypochlorite ions.
3. Campylobacter jejuni 8. E. histolytica o The disinfecting action of chlorine is mainly due to the
4. EHEC & ETEC hypochlorous acid and to a small extent due to the
5. Vibrio parahemolyticus hypochlorite ions.
3. Invasion of lymph nodes and blood stream o The hypochlorous acid is the most effective form of
(Penetrating) chlorine for water disinfection, it is 70-80 times more
Along with abdominal pain and diarrhea containing effective than hypochlorite ion.
WBCs and RBCs, this deeper invasion results in Method of Chlorination
systemic symptoms of fever, headache and o For disinfecting large bodies of water, following methods
leukocytosis, of chlorination are available:
Examples are 1. Salmonella typhi, 1. Chlorine gas First choice
2. Yersinia enterocolitica, and
52
2. Chloramine o The vaccine is best used in interepidemic period and
3. Perchloron or high test hypochlorite (HTH) should be offered to the most vulnerable and high risk
group.
251. Cell organelle affected in Wolmans Disease is o Currently, the three types of JE vaccines are in use:
1. Peroxisome (i). The mouse brain derived killed vaccine, which is
2. Lysosome based on either the Nakayama or beijing strains of
3. Liposome JE virus.
4. Dyctyosome (ii). The cell culture derived inactivated vaccine based
on the Beijing P-3 strain.
Ans. 2 (iii). The cell culture - derived live attenuated vaccine
Characteristics of Lysosomes based on the SA 14-14-2 strain.
1. Discovered by Christian de Duve o When immunizing children 1 -3 years of age the
2. Contains acid hydrolases,acid lipases,collagenase mouse brain derived vaccine provides adequate
3. ATP-dependent proton pumps in the membrane protection throughoutchildhood following 2 primary
maintain an acidic environment (pH 4.05.0) doses 2 weeks apart and boosters after 1 year and
subsequently at 3 yearlyintervals until the age of 10-
Lysosomal Diseases 15 years.
Tay-Sachs disease o Protective immunity develops in about one month
Hexosamidase A time (30 days) after the second dose.
Gauchers disease o Equally good childhood protection is obtained by a
Beta galactocerebrosidase single dose of the cell culture based live attenuated
I-cell disease vaccinefollowed by a single booster given at an
Absent mannose-6-phosphate tag interval of about one year,
o For travellers aged more than one year, visiting rural
252. Amplifier for Japanese encephalitis areas of endemic countries for at least 2 weeks, the
1. Horse establishedcurrent practice is to administer 3 primary
2. Pigs doses at days 0, 7 and 28.
3. Dogs o Alternatively 2 primary doses can be given 4 weeks
4. Monkey apart.
When continued protection is required booster should be
Ans. is '2 i.e., Pigs given after one year and then every 3 years.
In Japanese encephalitis
Pigs Amplifiers. 254. Age limit for HDI?
Cattle and buffalos Mosquito attractants 1. 25 to 85 yrs
Man Incidental dead-end host 2. 25 to 50 yrs
Herons Reservoir hosts 3. 15 to 45 yrs
4. 50 to 75 yrs
253. SA-14-14-2 -
1. Diploid cell inactivated Ans. is '1' i.e., 25 to 85 yrs
2. Killed vaccine o According to previous editions of Park (21st/e) the
3. Life long immunity minimum and maximum established values for life
4. Primary immunization 2 doses expectancy atbirth was 25 years and 85 years,
respectively.
Ans. is 3 i.e., Life long immunity (most probably) o However, Now the minimum established value is 20
o SA-14-142 is a cell-culture-derived live attenuated years and maximum value is the highest observed
vaccine. value during time series, i.e. the country which has the
o Primary immunization is given by a single dose highest value is taken as reference for maximum value.
followed by a booster after 1 years. For example themaximum life expectancy is observed
o I am not sure about option c, because no textbook has in Japan (83.4 in 2011). Thus 83.4 years is taken as
mentioned whether, SA-14-14-2 vaccine provides life upper (maximum limit).
longimmunity or not. But, almost all live o That means minimum value is established at 20 years
attenuatedvaccines provide life long immunity, and maximum value is established at 83.4 years.
therefore it may provide life longimmunity. Human development index (HDI)
"Protection for several years may be achieved with a single o HDI is a composite index combining indicators
dose of this vaccine _Vaccines: Expert Consult representing three dimensions
JE vaccine (i). Longevity (life expectancy at birth)
o Vaccination of population at risk has been (ii). Knowledge (Adult literacy rate and mean years
recommended. ofschooling, i.e. Gross enrolement ratio)

53
 (iii). Income (real GDP per capita in purchasing power Primary- Post central gyrus
parity in US dollars) Association area- parietal lobe
o The HDI is an index used to rank countries by level of Secondary area- sylvian fissure
human development.
o According to HDI countries are divided - size of the cortical receiving area for impulses from a
(i). Developed countries (High HDI 0.8) USA, particular part of the body is proportional to the use of the
Canada, Norway part
(ii). Developing countries (medium HDI 0.5 -
0.79)India Thumb and lips-maximum representation
(iii). Underdeveloped countries (Low HDI Vertical columnar arrangement
0.5)Seiera, Ethopia
257. All of the following are direct DNA interacting
Following information has been added in 22nd/e of cytotoxic agents except
Park 1. Melphalan
o Components of human development index have 2. Hydroxyurea
changed. Now it includes expected years of schooling 3. Carmustine
(insteadof adult literacy rate) and GNI per capita 4. Ifosfamide
(instead of GDP per capita).
Components of HDI Ans , 2
Recent (22nd/e of Park) Old (Previous editions)
1)Longevity:- Life 1) Longevity: - Life All other agents are alkylating agents , whereas
expectancy at birth expectancy at birth hydroxyurea is an anti metabolite acts at S phase of cell
2) Knowledge 2) Knowledge cycle indirectly affect DNA molecules.
Mean years of schooling Adult literacy rate
Expected years of 3) Income: - GDP per capita 258. The least common cause of neonatal mortality in
schooling India is -
3) Income: - GNI per capita 1. Prematurity
2. Congenital malformations
255. Stimulation of which brain area can modulate the 3. Birth asphyxia
sensation of pain? 4. LBW
1. Superior olivary complex
2. Locus ceruleus Ans. is '2' i.e., Congenital malformations
3. Periaquaductal gray o All the given options are causes of neonatal death in
4. Amygdala India; However, amongst the given options
congentialanomaly is the least common cause.
Ans. 3 o Causes of neonatal mortality in decreasing order of
frequency:
Endogenous analgesic system Prematurity & LBW > Severe infections > Birth
A. periaqueductal gray (PAG)-projects to nucleus raph asphixia > Congential anomalies > Neonatal
magnus and rostral ventromedial medulla tetanus > Diarrheal disease > other.
B. project to the dorsal horn of the spinal cord- release
serotonin and norepinephrine 259. 1ST sign of anterior uveitis -
C. Locus coerulus-Nor epinephrine 1. Keratic precipitate
D. Stress induced analgesia: 2. Aqueous flare
release of endogenous cannabinoids such as 2- 3. Hypopyon
arachidonoylglycerol (2AG) and anandamide acts on 4. Miosis
CB1(Euphoria) and CB 2 (Pain)receptors
Ans. is '2 i.e., Aqueous flare
256. Which body part has maximum representation in o Earliest sign of anterior uveitis Aqueous flare.
CNS? o Pathognomonic sign Keratic precipitate.
1. Urinary Bladder Clinical features of acute anterior uveitis
2. Lower limb o Acute anterior uveitis is the most common form of
3. Abdomen uveits, accounting for 60-70% of cases. It is
4. Thumb characterized bysudden onset and duration less than 3
months.Presentation is typical with sudden onset of
Ans. 4 unilateral pain,photophobia, redness, tacrimation and
blepherospasm. Vision may be normal initially.
However, later there may bedisturbance in vision due
Somatosensory cortical areas

54
 to ciliary spasm (induced myopia), corneal haze (due
to edema & KPs) and aqueous turbidity.
o External examination shows following signs:-
(i). Circumcorneal (ciliary) congestion Which has a
violaceous hue.
(ii). Corneal edema, posterior corneal opacities.
(iii). Keratic precipitates (KPs):- are proteinaceous cellular
deposits at the back of cornea.
(iv). Anterior chamber signs:- Aqueous cells. Aqueous flare,
hypopyon, hyphacmia (in hemorrhagic uveitis), deep
anterior chamber(lf posterior synachiac occurs).
(v). Ins signs:- Blurred & indistinct iris, i.e. muddy iris,
instead of being clear and sharply defined.
(vi). Pupillary signs: - Narrow (miotic) pupil, irregular
pupil due to segmental posterior syncchiac which
givesfestooned appearance (festooned pupil) when
dilated with atropine, sluggish pupillary reaction,
ectropionpupillae (evertion of pupillary margins),
occlusio pupillac (due to complete occlusion of pupil
by organized exudate).
260. Posterior staphyloma, most common cause
1. Trauma
2. Myopia
3. Iridocyclitis
4. Glaucoma
Ans. is 2' i.e., Myopia
Staphyloma
o Staphyloma is an abnormal protrusion of uveal tissue
through a weak and thin portion of cornea or sclera
o So, a staphyloma is lined internally by uveal tissue and
externally by weak cornea or sclera.
o Staphyloma is divided anatomically into : -
1. Anterior staphyloma: - Protrusion and adhesion of
iris to ectatic cornea. The most common cause is a
sloughing corneal ulcer which perforates and heals
with the formation of pseudocornea by the
organization of exudates and laying down of fibrous
tissue. It is lined internally by iris.
2. Intercalary staphyloma: - It occurs at the limbus. It is
lined internally by the root of iris and the anterior
most portion of the ciliary body. The causes are
perforating injuries to limbus, marginal corneal ulcer,
anterior scterilis, Scleromalacia perforans,
Complicated cataract surgery, secondary angle closure
glaucoma.
3. Ciliary staphyloma : This affects the ciliary zone that
includes the region upto 8 mm behind the limbus.
The ciliary body is incarcerated in the region of scleral
ectasia. Causes arc Developmental glaucoma. Primary
or secondary glaucoma end stage, scleritis, trauma to
ciliary region.
4. Equatorial staphyloma : - This occurs at the
equatorial region of the eye with incarceration of the
choroid.
Causes are scleritis, degenerative myopia and chronic
uncontrolled glaucoma.
55
5. Posterior staphyloma : - Occurs at posterior pole and
is lined internally by choroid. Degenerative high
axial myopia is the most common cause.
261. Which is not a cataract surgery-
1. Lensectomy
2. Goniotomy
3. Phacoemulsification
4. IOL
Ans. is 2' i.e., Goniotomy
o Goniotomy is done for glaucoma.
o Extracapsular cataract extraction (ECCE) by
phacoemulsification with posterior chamber IOL is the
procedure ofchoice for cataract.
o Lensectomy is done in congenital cataract.
Operative techniques available
o Following operative procedures are available for
cataract extraction :-
1)Extracapsular cataract extraction (ECCE)
The nucleus, cortex and central part of the anterior
capsule are removed leaving behind intact posterior
capsule, peripheral part of anterior capsule and zonules.
Presently, extracapsular cataract extraction
with posterior chamber lens implantation (ECCE with PCL)
is the surgery of choice for almost all types of
cataract. The only absolute contraindication for ECCE is
subluxation and dislocation of lens.
Techniques for ECCE are:-
i) Conventional ECCE
ii) Manual small incision cataract surgery
iii) Phacoemulsification
2) Intracapsular cataract extraction (ICCE)
The lens is removed in toto as one single piece, i.e., the
nucleus and cortex are removed with the
capsule after breaking the zonules. There is no support left
for posterior chamber IOL, therefore, only
anterior chamber IOL can be implanted. At present, the
only indication of ICCE is markedly subluxated or
dislocated lens in which zonules arc already broken, so
ECCE cannot be done. ICCE is contraindicated
in young patients (< 40 years) because zonules are too
strong.
3) Phacoemulsification
o It is nothing else but an advancement in the method of
doing ECCE. Here the nucleus is converted into
pulp or emulsified using high frequency sound waves,
and then sucked out of the eye through a small
(3.2 mm) incision. A special foldable IOL is then
inserted into the posterior chamber through the
same incision. ECCE by phacoemulsification with
foldable posterior chamber IOL is the procedure
ofchoice for cataract.
o The steps in phacoemulsification include :(i)
Corneoscleral incision, (ii) Continuous curvilinear
capsulorrhexis, (iii) Hydrodissection and
hydrodelineation (iv) Emulsification and aspiration of
nucleusand then cortex, (v) Foldable IOL implantation
in posterior chamber,
o Recovery with phacoemulsification is fastest as 3. Retrobulbar neuritis
incision is very small and no sutures are taken. 4. Keratoconus

Ans. is 3' i.e., Retrobulbar neuritis

262. Vitamin B12 deficiency causes - o Swinging flash light test is used for relative afferent
1. Centrocaecal scotoma pathway dfect (RAPD), which is most characteristic of
2. Binasal hemianopia lesions in the optic nerve,
3. Constriction of peripheral field o Thus it is positive in retrobulbar neuritis.
4. Bitemporal hemianopia Marcus Gunn pupil
o Marcus Gunn pupil is seen in relative afferent pathway
Ans. is '1' i.e., Centrocaecal scotoma defect (RAPD)
o Vitamin B12 deficiency causes optic neuritis, o An incomplete optic nerve lesion or retinal disease
o Most common visual field defect in optic neuritis is cause it (in contrast to amaurotic light reflex, where
central or centrocaecal scotoma. there is total afferent pathway defect). It is best tested
Important facts by swinging flash light test.
o Earliest visual field defect in primary open angle o To perform this test, B bright flash light is shone to
glaucoma Isopeteric contraction. one pupil and constriction of that pupil is noted
o Earliest clinically significant visual field defect in o Then the flashlight is quickly moved to the
primary open angle glaucoma Paracentral scotoma. contralateral pupil and the response in that pupil is
o Visual field defect in rheugmatogenous retinal noted,
detachment Loss ofperipheral field. o This swinging to and fro of the flashlight is repeated
o Visual field defect in retinitis pigmentosa Tubular several times while the pupillary response is observed,
vision. o Normally, both pupils constrict equally and the pupil
o Most common visual field defect in optic neuritis to whom light is transferred remains tightly
Central or centrocaecal. constricted,
o Usual field defect in papilledema Enlargement of o In the presence of relative afferent pupillary defect in
blind spot and progressive contraction of visual field. one eye, both the pupil will dilate when the flash light
o Visual field defect in Lebers optic neuropathy is moved from the normal to the abnormal eye.
Centrocaecal. o This is a paradoxical resposne.
o Characteristic visual field defect in anterior ischemic o This is called Marcus Gunn pupil and is the earliest
optic neuropathy Altitudinal visual field defects. indicator of optic nerve disease even in the presence of
a normal visual acuity.
263. Intact cornea can be penetrated by - o Relative afferent pupillary- defect (RAPD) or Marcus
1. Gonococcus Gunn pupil is a reliable and objective sign of unilateral
2. Pseudomonas or assymmetric disease or any lesion in afferent
3. Streptococcus pupillary pathway, Le., retina, optic nerve, optic
4. Pneumococcus chiasma, optic tract or midbrain (pretectal nucleus).
o However, RAPD is most characteristic of lesions in the
Ans. is 1' i.e., Gonococcus optic nerve.
o A few species of bacteria are capable of penetrating an
intact corneal epithelium - 265. Not a symptom of angle closure glaucoma -
i) Neisseria gonorrhoea 1. Blurring of vision
ii) Coryncbacterium diphtheriea 2. Coloured Halos
iii) Haemophilus agyptus 3. Metamorphosia
iv) Neisseria meningitidis 4. Headache
v) Listeria species
o Bacteria which cause corneal ulcer after epithelial Ans. is 3' i.e., Metamorphosis
injuries are - o Transient blurring of vision and headache is seen in
i) Pseudomonas stage of constant instability.
ii) Pneumococcus o Coloured halos are seen in acute congestive stage.
iii) Staphylococcus aureus Clinical features of primary angle clasure glaucoma
iv) Morexella o The disease is generally bilateral, though assymetrical.
v) Streptococcus epidermids A number of clinical subtypes have been described,
vi) Enterobacterias whichmay or may not show a stepwise progression in
a given eye.
1) Latent PACG (PACG suspect or Prodromal stage):- These
264. Swinging light test is positive in - eye arc identified by shallow anterior chamber
1. Conjunctivitis associated with an occludable angle. There are no
2. Glaucoma symptoms except for occasionally complain of halos

56
around light and transient haziness of vision at this stage.
The only gonioscopic finding is very narrow angle
(<20).IOP is normal. Two provocative test have been
described i) Prone-darkroom provocative test: - It is
best physiological test. Patient is made to lie prone in a
darkroom. There is an increase in IOP > 8 mm Hg.
ii) Mydriatic / cycloplegic provocation test; Is not
preferred because it is not physiological. A mydriaticis
used to dilate the pupil and there is > K mm rise in IOP
2) Subacute / intermittent PACG (Stage of constant
instability):- Patients have shallow anterior chamber with
occludable angle and physiological factors like dim light or
watching a movie in a darkened cinema hallprecipitate
pupillary block and rise in IOP. The patient complains of
transient blurring of vision,coloured halos arround light,
headache, browache and eyeache. On examination the eye
is white hut notcongested. Provocative tests arc positive.
Between these recurrent attacks, eye is free of symptoms
and onlyshows signs of a narrow angle recess, clumping of
pigment in the angle and occasional peripheral synechia.
3) Acute primary angle glaucoma (acute congestive
glaucoma or acute angle closure glaucoma): - Is caused by
sudden occlusion of the entire angle with a resultant acute
rise of IOP to extremely high level. The attack
usually does not terminate of its own. The clinical features
are:-
A) Symptoms: Sudden onset of very severe pain in the
eye which radiates along the branches of 5thnerve and is
frequently associated with nausea, vomiting and
prostrations. Patient developsrapidly progressive loss of
vision, redness, photophobia and lacrimation. Coloured
halos are seen.
B) Signs
o Lid edema
o Conjunctiva is chemosed and congested (both
conjunctival & ciliary vessels are congested) a Cornea
is oedematous and insensitive
o Anterior chamber is very shallow & with aqueous flare
o Angle of anterior chamber is closed (on gonioscopy)
o Iris is discoloured
o Pupil is semidilated, vertically oval and fixed. It is non
reactive to both light and accommodation.
o IOP is markedly raised (40- 70 mm Hg)
o Optic disc is oedematous & hypercmic
4) Chronic primary angle closure glaucoma:- It results
from gradual synechial closure of the angle ofanterior
chamber. There is constantly elevated IOP, decreased
visual aucity, Visula field defect (like POAG).
The eyeball is white and not congested.
5) Absolute primary angle closure glaucoma (absolute
glaucoma):- If chronic phase is untreated it gradually
passes into the final phase of absolute glaucoma where the
eye is painful, irritable and completely blind.
Onexamination there is perilimbal reddish blue zone,
caput medusae, hazy cornea with bullous keratopathy or
filamentry keratitis, atrophic iris, raised IOP, fixed dilated
pupil, glaucomatous optic disc atrophy andstony hard
eyeball.
57
266. Eale's disease is -
1. Retinal hemorrhage
2. Vitreous hemorrhage
3. Conjunctival hemorrhage
4. Choroidal hemorrhage
Ans. is 2 i.e., Vitreous hemorrhage
Eale's disease
o Eale's disese is an idiopathic inflammatory venous
occlusion that primarily affects the peripheral retina of
young adult (20-30 yrs) male.
o It is characterized by recurrent bilateral vitreous
hemorrhage; therefore, also referred to as primary
vitreous hemorrhage.
o Disease is bilateral and patients commonly present
with sudden onset of floaters (black spots) in front of
the eyeor sudden painless loss of vision due to
vitreous hemorrhage,
o The hemorrhage clears up spontarcously, but
recurrences are very common.
o On examination, retinal changes include perivascular
phlebitis, perivascular exudates, superficial (flame
shaped)hemorrhages, peripheral nonperfusion
ischemia and neovascularization
o Medical treatment in the form of oral corticosteroid is
the treatment of choice.
o A course of ATT has also been recommended for
selected cases as many workers consider Eale's
disease to be ahypersensitivity reaction to tubercular
protein, a Laser photocoagulation is indicated for
retinal neovascularization.
o Vitroretinal surgery is required for non - resolving
vitreous hemorrhage and retinal detachment, a
Complications of hales disease include proliferative
vitreorelinopathy, fractional retinal detachment,
rubeosis iridis and neovascular glaucoma.
267. Neurotransmitter employed by rods and cones is
1. Dopamine
2. Serotonin
3. Glutamate
4. Nitric oxide
Ans. 3

268. MC orbital tumor -
1. Nerve sheath tumor
2. Hemangioma
3. Lymphoma
4. Meningioma
Ans. is '2' i.e., Hemangioma
o Most common orbital tumor Cavernous
hemangioma.
o Most common malignant orbital tumor Lymphoma.
IMPORTANT FACTS
Most common intraocular tumor in adults is
metastasis. Metastasis is particularly common from
carcinoma of breast and lung.
Most common primary intraocular tumor in adults is
uveal melanoma. Most of the uveal malignant
melanoma arise in choroid.
Most common primary intraocular tumor is children is
retinoblastoma
Most common orbital tumors in adults are benign
vascular tumors Cavernous hemangioma
Most common malignant orbital tumor in adult
lymphoma
Most common orbital tumors in children are benign
tumors Dermoid cyst capillary hemangioma
Most common malignant orbital tumor in children
rhabdomyosarcoma
Overall most common primary malignant tumor of eye
is malignant melanoma followed by retinoblastoma
Most common malignant eyelid tumor Basal cell
carcinoma
Most common epithelial tumor of lacrimal gland
Pleomorphic adenoma (benign mixed tumor)
Overall most common tumor of lacrimal gland
Lymphoid tumour and inflammatory pseudo - tumors
Most common malignant tumor of conjunctiva
Squamous cell carcinoma
58
Most common malignant tumor of cornea
Squamous cell carcinoma
269. A person with neck nude and B type
tympanogram
1. Acoustic neuroma
2. Nasopharyngeal CA
3. Angiofibroma
4. None
Ans. is 2' i.e., Nasopharyngeal CA
o Information in this question:
i) Cervical adenopathy (Seek node)Most common
presentation of nasopharyngeal carcinoma,
ii) Type B tympanogram:- Indicates serous otitis
media, which may be a complication of
nasopharyngeal carcinoma due to eustachian tube
blockade,
o Thus, among the given options, nasopharyngeal
carcinoma is the answer of choice.
Clinical features of nasopharyngeal carcinoma
o Symptomatology of nasopharyngeal carcinoma is
divided into five main groups:-
1) Nasal symptoms
o Nasal obstruction, nasal discharge, denasal speech
(rhinolalia clausa), epistaxis.
2) Otologic symptoms
o Otologic symptoms are due to obstruction of
eustachian tube.
o This results in serous or suppurative otitis media.
Which causes conductive deafness.
o Presence of unilateral serous otitis media in adult
should raise the suspicion of nasopharyngeal
carcinoma a Tinnitus and dizziness may occur.
3) Ophthalomoneurological symptoms
o These symptoms occur due to spread of tumor to the
surrounding regions.
o Squint and diplopia due to involvement of VI th cranial
nerve.
o Ophthalmoplagia due to involvement of IVrd, IVth& Vim
cranial nerve.
o Facial pain X reduced corneal sensations due to Vth
nerve involvement a Exophthalmos and blindness due
to direct extension into the orbit.
o Jugular foramen syndrome (IXth, Xth, XIth cranial nerve
involvement) due to pressure by enlarged lateral
retropharyngeal lymph nodes.
o Cranial nerve XIIth involvement due to extension of
growth to hypoglossal canal.
o Horners syndrome due involvement of cervical
sympathetic chain.
4) Neck mass:- It is the most common presentation
(60-90%)
o Due to cervical lymphadenopathy.
5) Distant metastasis
o Involve bone, lung, liver and other sites.
270. Impedence matching occurs d/t -
1. Difference of surface area of tympanic membrane
and foot plate
2. Semicircular canal fluid
3. Utricle & Saccule
4. None
Ans. is 1 i.e., Difference of surface area of tympanic
membrane and foot plate
o Impedence matching or transformer action of middle
ear is due to:-
i) Hydraulic action of tympanic membrane due to
difference in surface area of TM and stapes footplate.
ii) Lever action of ossicles.
Impedence matching
o The middle ear couples sound signals from the ear
canal to the cochlea primarily through the action of the
tympanic membrane and ossicular chain. Sound
energy that reaches the tympanic membrane is
conducted across ossicular chain and is concentrated
in the stapes footplate. The transformer action of
middle ear is accomplished by :-
1) Hydraulic action of tympanic membrane
o The main transformer action of middle ear comes from
the tympanic membrane. The ratio of functioning area
(affective vibrating area) to the area of stapes
footplate is 17: 1, and this is the mechanical advantage
provided
by the tympanic membrane which increases the sound
pressure at the footplate. You should keep in mind that
though the ratio of functional area of tympanic
membrane to footplate is 17: 1, ratio of total area of
tympanic membrane is 21 : 1 (As the effective
vibratory area of tympanic membrane is 2/3rdof total
area, mechanical advantage is provided only by
2/3rdof the total area).
2) Lever action of the ossicles
o Ossicular lever ratio is 1.3: 1 as handle of malleus is
1.3 times longer than the long process of the incus.
This provides mechanical advantage of 1.3.
o So, the combined (total) mechanical advantage
(product of area ratio and lever action of ossicles is) -
17*1.3 = 22:1.
3) Curved membrane effect
o Movements of tympanic membrane are more at
the periphery than at the centre where malleus
handle is attached. This too provides some leverage.
271. Which of the following viruses causes an acute
febrile rash and produces disease in
immunocompetent children but has been associated
with transient aplastic crises in persons with sickle
cell disease?
1. Rubeola
2. Varicella-zoster
3. Parvovirus
4. Rubella
59
Ans. 3
Parvovirus B 19 is the causative agent of erythema
infectiosum (fifth disease). It is associated with transient
aplastic crisis in persons with hereditary hemolytic
anemia. In adults, it is also associated with polyarthralgia.
272. Transport medium for Streptococcus will be
1. Pikes medium
2. Stuarts medium
3. VR medium
4. Selenite F medium
Ans. 1
Transport media: used to transport the specimen from
collection place to laboratory. Transport media mainly
used to avoid multiplication of commensals in the
particular sample.
o Stuart (charcoal swab), Amies medium -Gonococcus
o Pikes - Streptococcus
o Venkatraman Ramakrishnan medium, autoclaved sea
water, Alkaline salt water- Vibrio
o Buffered glycerol saline Typhoid bacilli
o Carry Blair medium Enteric pathogen
273. The effect of progesterone on lipids
1. Lowers LDL, increases HDL
2. Lowers LDL and HDL
3. Lowers HDL and increases LDL
4. Increases LDL and HDL
Ans. 3.
While part of the administered progestogen is metabolized
to oestrogen, it is also partly metabolized to testosterone.
If administered to a patient during pregnancy, some
progestogens have virilizing effect upon a female fetus.
Lipid metabolism decreases HDL but increases low-density
lipoprotein. Thus, it is harmful to the heart.
It improves the immune response
274. Identify the procedure
 1. Marshall burns
2. Mauriceau smellie veit technique
3. Leopold maneuvre
4. Ritgen maneuver

Ans. 3.

277. The first sign of puberty in girls is

1. Menarche
1. Amniocentesis 2. Breast budding
2. Hegars sign elicitation 3. Growth spurt
3. Bimanual compression 4. Pubic and axillary hair growth
4. Ritgen maneuver
Ans. 2.
Ans. 2.
Tanner and Marshall described five stages of pubertal
275. All are true about PCOS except changes in a normal girl. These are in the following
1. Persistently elevated LH sequence (Figure 4.3):
2. Increased LH/FSH ratio Physical growth and weight gain.
3. Increased DHEAS Development of secondary sex orgAns. A.nd breast
4. Increased prolactin development-around 10-12 years.
Pubic and axillary hair growth a year later.
Ans. None Development of ovaries and the genital organs.
Growth spurt and menstruation.
Endocrinological changes are as follows:
1. Oestrone/E2 level rises. 278. Identify 2 in the picture
2. LH level is raised over 10 IU/ml.
FSH level remains normal, but FSH/LH ratio falls.
3. SHBG level falls due to hyperandrogenism.
4. Testosterone and epiandrostenedione levels rise.
Testosterone >2 ng/ml, free T >2.2 pg/ml (Normal level
0.2-0.8 ng/ml)
Normal androstenedione level is 1.3-1.5 ng/ml.
DHEA > 700 ng/ml suggests adrenal tumour.
5. Prolactin is mildly raised in 15% cases.
6. Fasting insulin is more than 10 mIU/l in PCOS.
7. Thyroid function tests may be abnormal
(hypothyroidism).
8. 17 -hydroxyprogesterone in the follicular phase > 300
ng/dl suggests adrenal hyperplasia due to 21 hydroxylase
deficiency.

276. Identify the maneuver 1. Obstetric conjugate

2. Diagonal conjugate
3. Anatomic conjugate
4. None

Ans. 1.

279. The pH of vagina in adults is

60
1. 3.5- 4.5 DeLancey introduced three level systems of support.
2. 4.5-5.5 Level I-Uterosacral and cardinal ligaments support the
3. 5.5- 6.5 uterus and vaginal vault.
4. 6.5- 7.5 Level II-Pelvic fascias and paracolpos which connects the
vagina to the white line on the lateral pelvic wall through
Ans. 2. arcus tendinous.
Level III-Levator ani muscle supports the lower one-third
The vaginal secretion is small in amount in healthy of vagina.
women and consists of white coagulated material. When it
is examined under the microscope, squamous cells which 282. Identify the type of placenta
have been shed from the vaginal epithelium and
Doderlein's bacilli alone are found. Doderlein's bacillus is
a large gram-positive rod-shaped organism, which grows
anaerobically on acid media. The vaginal secretion is acidic
due to the presence of lactic acid, and this acidity inhibits
the growth of pathogenic organisms. The pH of the vagina
averages about 4.5 during reproductive life. The acidity,
which is undoubtedly oestrogen-dependent, falls after
menopause to neutral or even alkaline. Before puberty, the
pH is about 7. This high pH before puberty and after
menopause explains the tendency for the development of
mixed organism infections in these age groups.
1. Succinate lobe
2. Battledore placenta
280. Comment on this CTG 3. Velamentous placenta
4. Marginal cord insertion

Ans. 3

283. Minimum effective dose of oestrogen in OCPs is

1. 20 mcg
2. 30 mcg
3. 40 mcg
4. 50 mcg

Ans. 1.

1. Normal Combined oral pills

2. Early deceleration Combined oral pills contain a mixture of ethinyloestradiol
3. Late deceleration (EE2) in a dose of 20 to 30 g and an orally active
4. Variable deceleration progestogen which is a 19-norsteroid. Mala-D contains 0.5
mg of d-norgestrel and Mala-N contains 1 mg
Ans. 4. norethisterone; these are available free of cost in India.
The tablets are taken starting on the second day of the
281. All are primary supports of uterus except cycle for 21 days. A new course of tablets should be
1. Transcervical ligament commenced 7 days after the cessation of the previous
2. Pubocervical ligament course. They should be taken at a fixed time of the day,
3. Uterosacral preferably after a meal.
4. Broad ligament

Ans. 4. 284. Identify the pelvis type A

The supports of the uterus and the bladder are seen to be
triradiate condensation of endopelvic fascia:
1. The anterior spoke is the pubocervical fascia or so-
called pubocervical ligament.
2. The lateral spoke is Mackenrodt's ligament.
3. The posterior spoke is the uterosacral ligament. 1. Android
2. Gynecoid
SUPPORTS OF THE GENITAL TRACT 3. Anthropoid
4. Platypelloid
61
 luteum. The menstruation comes on time, is prolonged but
Ans. 2. not heavy. Progestogen can suppress the bleeding, but
needs to be taken on tapering dose for 20 days to complete
285. Best Hormonal contraceptive for sickle cell the cycle.
anemia patient is
1. Ocp 289. In ca ovary inguinal lymph nodes are involved in
2. Pop stage
3. Cu-T 1. Stage II
4. None 2. Stage III a
3. Stage IIIc
Ans. 2. POP progesterone only pill 4. Stage IVb

POP is contraindicated in liver diseases, vascular disorders Ans. 4.

and breast cancer. It is safe in sickle cell anaemia.
FIGO revised the staging of carcinoma ovary in January
286. Hypokalemic paralysis is side effect of 2014 and according to the new staging inguinal LN
1. Gossypol involvement is stage IV b.
2. DMPA
3. Testosterone enanthate 290. Mc benign epithelial ovarian tumor is
4. Cyproterone acetate 1. Serous cystadenoma
2. Mucinous cystadenoma
Ans. 1. Gossypol 3. Brenner tumor
Its use as a male contraceptive was discovered in China. 4. Ovarian fibroma
Gossypol is a yellow pigment isolated from cottonseed oil.
It is administered orally 10 to 20 mg daily for 3 months Ans. 1
and thereafter 20 mg twice weekly. The action is directly
on the seminiferous tubules inhibiting spermatogenesis Serous cystadenoma and cystadenocarcinoma
without altering FSH and LH levels. The side effects such as Serous cystadenoma and cystadenocarcinoma are amongst
weakness, hypokalaemia and permanent sterility in 20% the most common of cystic ovarian neoplasms, accounting
cases limit its use. about 50% of all ovarian tumours; of these, 60-70% are
benign, 15% borderline and 20-25% are malignant.
287. Red degeneration of uterine fibroid is mc in
1. First trimester 291. Most common CNS manifestation of HIV Infection
2. Second trimester is:
3. Third trimester 1. Acute Meningitis
4. Peurperium 2. Encephalopathy
3. Vacuolar myelopathy
Ans. 2. 4. Dementia
Red degeneration
This complication of uterine myomas develops most Ans. 4
frequently during pregnancy, although it is not rare in HIV Encephalopathy also called HIV - Associated
cases of painful myomas in women over the age of 40. The dementia or AIDS dementia.
myoma becomes tense and tender and causes severe This is generally a late complication of HIV infection, it
abdominal pain with constitutional upset and fever. The can be seen patients with CD4 count >350 cells.
tumour itself assumes a peculiar purple red colour and
HIV encephalopathy is a sub-cortical dementia while
develops a fishy odour. If the tumour is carefully examined,
. Alzheimer's is a cortical dementia
some of the large veins in the capsule and the small vessels
in the substance of the tumour will be found thrombosed Alzheimer's disease is the most common cause of
dementia in elderly.
288. Halban disease is due to Most important risk factor for Alzheimer'^ disease is
1. Persistent corpus luteum age.
2. Deficient corpus luteum
3. Persistent trophoblast 292. All are the risk factors for coronary artery disease
4. Deficient trophoblast except:
1. LDL
Ans. 1. 2. HDL
3. Smoking
Irregular shedding (Halban's disease) 4. Hypertension
It is rare and self-limited. It is due to persistent corpus

62
Ans. 2 systemic sclerosis and serologically by high titres of
Some important risk factors for Atherosclerosis: antibodies to RNP Particle containing UI RNP. Two factors
Fixed are important in lending distinctiveness to MCTD are:
Family history The paucity of renal disease.
Age Extremely good response to corticosteroid.
Sex (male) Modifiable Some important points about connective tissue
Smoking disorder:
Haemostatic variables Antinuclear antibodies in autoimmune disease.
Hypertension Anti double stranded DNA-S (more specific
Sedentary life styles than anti SM antibody).
Lipid disorders Anti Histone Antibodies-Z)rz/g induced lupus
Obesity erythrocytosis
DM Anti sm antibody>SLE
Diet Anti DNA topoisornerasc antibody
sclerosis
Atherosclerotic vascular disease may manifest as
Antibodies of Ribonucleoprotein Antigen
coronary heart disease, cerebrovascular disease or
containing ULRNP> Mixed connective tissue
peripheral vascular disease. Occult coronary artery
disorder.
disease is common in those who present with other Antimitochondrial antibody>Primary biliary
forms of atherosclerotic vascular disease. So risk factors cirrhosis.
for atherosclerosis is also are the risk factors for CAD.
295. Microangiopathic Hemolytic anemia seen in:
293. Lung carcinoma most common associated with: 1. HUS
1. Asbestosis 2. HTN
2. Silicosis 3. SLE
3. Byssinosis 4. All
4. Beryllium
Ans. 4
Ans. 1 Micro-angiopathic Hemolytic anemia occurs when
Remember some important points. red blood cells are forccd to squeeze through
Silicosiscurrently the most prevalent chronic abnormally narrowed small vessels. Narrowing is
occupational disease in the world most often caused by fibrin deposition in
Silicosis is associated with an increased association with DIC. Other causes of micro-
susceptibility to Tuberculosis. The radio logical angiopathic hemolytic anemia are:
featureEGG SHELL calcification in the hilar Malignant hypertension
lymphnodes. SLE
Berylliosis cause an interstitial granulomatous Thrombotic Thrombocytopenic purpura.
disease similar to Sarcoidosis. HUS
The most dangerous particles to cause Disseminated cancer.
Pneumoconiosis from 1 to 5 micrometer in The common feature among all these disorders is a Micro
diameter because they may reach in the vascular Lesion that cause mechanical injury to
terminal small airways, air sacs and settle in circulating Red blood cells. In blood smear in the form of
their lining. red cell fragments (schisocytes) burr cells, helmet cells
Cotton dust is associated with Byssinosis. and triangle cells are seen. Some important Point:
Sugarcane dust is associated with Bagassois Most common cause of Anemia in world is Iron
deficient Anemia.
294. Mixed connective tissue disease includes all the Most sensitive and specific test for diagnosis of from
following except: deficiency is serum ferritin levels.
1. Polymyositis Hyper segmented neutrophilis are a feature of
2. RA megaloblastic anemia and not iron deficient anemia.
3. Osteoarthritis Cause of microcytic hypochromic anemia Mnemonics:
4. Systemic sclerosis Tiny CLIPS ' Iron deficient Anemia
Thaiassaemia
Ans. 3 Sideroblastic anemia,
Mixed connective tissue diseases (MCTD) are sometimes
Lead poisoning
used to describe the disease seen in a group of patient Anemia of chronic disease.
who are identified clinically by the coexistence of features Pyridoxin deficit anemia.
suggestive of SLE. Polymyositis, Rheumatoid arthritis and
63
296. "a" wave in JVP indicates:
1. Atrial systole Ans. D
2. Ventricular systole Renal failure consequent on liver failure can occur
3. Atrial relaxation
in cirrhosis. The kidney's they are intrinsically
4. Tricuspid regurgitation
normal and renal failure is thought to result from
Ans. A altered systemic blood flow including diminished
A wave: Arc positive waves due to distention produced renal blood flow:
by right atrial contraction Large a waves: Indicate atrium It occurs in advanced cirrhosis at most always
is contracting against increased resistance tricuspid and ascites
stenosis, pulmonary stenosis, pulmonary hypertension. Absence of proteinuria or abnormal urinary
Cannon S waves sediment.
Regularly: During junctional rhythm. Urine sodium excretion below lOmmol/day.
Irregularly: complete Heart Block. Serum Na t- concentration < 130 m Eq/L?
Absent a waves: Atrial Fibrillation Urinary osmolality greaterthan
plasma osmolality.
297. Anti mitochondrial Ab seen typically in: Urine volume < 500 ml/day.
1. Primary Biliary cirrhosis
2. Hepatitis B
3. Hepatitis C 299. In infant LRTI is MC caused by:
4. Hepatitis A 1. Streptococci
2. RSV Viruses
Ans. 1 3. H. Influenza
Primary Biliary cirrhosis is a disease characterized by 4. Mycoplasma
chronic inflammation and fibrous obliteration of
intrahepatic bile duclioles due to an unknown (primary) Ans. B
stimulus. Etiology RSV virus is m/c cause of bronchiolitis in Infants. Doc-
PBC is believed to due to an autoimmune etiology as it is Ribavirin. Epiglottis is most commonly caused by H.
often associated with other auto immune disorders such Influenzae.
as Some Important points:
CRCST syndrome: Calcinosis, Raynaud's Encephalitis>is the Inflammation of the brain
phenomena, Esophageal dysmotility, Sclero- parenchyma Meningitises an acute purulent infection with
dactily. Telangiectasia in the subarachnoid space. The meninges, the
Sicca syndrome subarachnoid space and brain parenchyma are all
Autoimmune thyroiditis frequently involved in the inflammatory reaction with
Renal tubular acidosis meningoencephalitis. The most common cause of sporadic
Anti mitochondrial antibody (IgG is positive) viral encephalitis HSV -I
The most common cause of Epidemic viral
Clinical feature
encephalitis- Arbovirus
Most patients arc asymptomatic.
Japanese encephalitis virus is an arbovirus is one
Pruritis is commonest/earliest symptom
of the most common causes of encephalitis
Jaundice
outbreak.
Deficiency of fat soluble vitamin due to
The most common cause of viral meningitis is ->
malabsorption leads to:
Enterovirus
Vit D deficiency Bone painOsteomyelitis
Vit K deficiency- bleeding bruising
Vit A deficiency~Night Blindness IXanthelisma 300. Megaloblastic anemia is caused by:
and Xanthomas arc due to elevation of serum 1. Diphyllobothriumlatum
lipids.Lab finding 2. H-NaNa
Increased Serum alkaline phosphates.Positive 3. Taeniasaginata
mitochondrial antibody sensitive and specific. 4. Echinococcusgranulosis

298. Hepatorenal syndrome characterised by all Ans. 1

except: Habitat: Adult worm lives in small intestine (ileum or
1. No proteinuria jejunum) of man D. Latum is the longest tapeworm found
2. Normal intrinsic'kidney. in man. Life cycle:
3. Liver failure
4. Urine osmolality less than plasma osmolality
64
The worm passes its life cycle in one definitive host and
Two intermediate host. Definitive host: Man is the main
definitive host Intermediate host:
First intermediate host: Small copepods mainly of genra
Diaptomus and Cyclops Second intermediate host:
Freshwater Fishes. Humans become infected when they
eat undercooked raw or lightly salted meat or roe from
infected freshwater fishes.
Pathogenicity:
Most human infections arc caused by only one tape worm
and cause no or very vague ill effects.
Patient may develop fatigue, weakness, diarrhea and
numbness of extremities. Some Patient develops
mechanical obstruction. In few cases pernicious anemia
may develop due to B12 deficiency. D. Latum has been
shown to absorb as much as 80-100% of a single oral
dose of vit- B12 thereby competing with the host for
this important vitamin. Treatment of choice:
Niclosamide and praziquantel Important:
Vit B12 Absorb in the ILEUM.
Iron is absorbed in the Duodenum.

65