AIIMS Nov 2013
RADIOLOGY
1. Which of the folwoing indicates radiograph contrast induced nephropathy?
A. Increased creatinine levels
B. Decreased urine output
C. Increased bilirubin
D. Decreased bilirubin
1. Ans A. Increased creatinine levels
REF :
1. http://emedicine.medscape.com/article/246751-overview : Contrast-Induced Nephropathy Author: Renu Bansal, MD; Chief Editor: Vecihi Batuman,
2. American Journal of Roentgenology. 2004;183: 1673-1689. 10.2214/ajr.183.6.01831673
Contrast-induced nephropathy (CIN) is defined as the impairment of renal function and is measured as either a 25% increase in serum creatinine (SCr) from baseline or 0.5 mg/dL (44 µmol/L) increase in absolute value, within 48-72 hours of intravenous contrast administration.
For renal insufficiency (RI) to be attributable to contrast administration, it should be acute, usually within 2-3 days, although it has been suggested that RI up to 7 days post–contrast administration be considered CIN; it should also not be attributable to any other identifiable cause of renal failure. A temporal link is thus implied. Following contrast exposure, SCr levels peak between 2 and 5 days and usually return to normal in 14 days.
Complications
CIN is one of the leading causes of hospital-acquired acute renal failure. It is associated with a significantly higher risk of in-hospital and 1-year mortality, even in patients who do not need dialysis. Nonrenal complications include procedural cardiac complications (eg, Q-wave MI, coronary artery bypass graft [CABG], hypotension, shock), vascular complications (eg, femoral bleeding, hematoma, pseudoaneurysm, stroke), and systemic complications (eg, acute respiratory distress syndrome [ARDS], pulmonary embolism). There is a complicated relationship between CIN, comorbidity, and mortality. Most patients who develop CIN do not die from renal failure. Death, if it does occur, is more commonly from either a preexisting nonrenal complication or a procedural complication.
Other renal function markers
The use of SCr as a marker of renal function has its limitations. Indicators such as the estimated glomerular filtration rate (eGFR) and cystatin C are increasingly considered to be more reliable and accurate reflectors of existing renal function.[3, 4]
The eGFR can be calculated using the Modification of Diet in Renal Disease (MDRD) formula or the Cockroft-Gault formula. The Cockroft-Gault formula calculates eGFR using age, sex, and body weight, which are factors that, independent of GFR, influence SCr. The MDRD equation also includes blood urea nitrogen (BUN) and serum albumin.
The eGFR works best at low creatinine values. SCr and GFR share a curvilinear relationship. At lower SCr values, doubling SCr is associated with a corresponding 50% decrease in GFR. However, in elderly patients with chronic kidney disease(CKD) who have high SCr values at baseline, a 25% rise in SCr is actually indicative of a relatively modest reduction in GFR. Nonetheless, even a 25% increase in SCr in this situation has been shown to have great impact, especially in terms of inhospital and 1-year mortality.[5]
Serum cystatin C is a serum protein that is secreted by nucleated cells. It is freely filtered by the glomerulus and has been found to be an accurate marker of GFR. Compared with SCr, cystatin C changes much earlier after contrast administration and is not subject to confounding factors, such age, sex, and muscle mass, that influence SCr values independent of the underlying GFR. Cystatin C is increasingly being used as a marker of renal function in cardiac surgical patients.
2. Best investigation for diagnosis of H Type TO Fistula?
A. Tracheobroncoscopy
B. Oesophagoscopy
C. CT scan
D. X-ray
2. Ans : A > D
Adam: Grainger & Allison's Diagnostic Radiology, 5th ed. Chap 65 states :
Now no literature directly states the best investigation and hence the answer has to be inferred.
Neonates with an H-type fistula commonly have an abdomen distended by gas. The fistula is easy to miss on a routine upper GI study. An oesophogram with the patient placed prone and using a horizontal X-ray beam is recommended. The contrast medium is injected under pressure, via a nasogastric tube, with its tip in the distal oesophagus. The tube is slowly withdrawn under fluoroscopic guidance. The majority of these fistulas are seen at the level of the thoracic inlet. Combined bronchoscopy and oesophagoscopy should be performed if there is a high clinical index of suspicion with negative imaging.
So we conclude that plain radiographs can be misleading, a contrast esophagogram may demonstrate the fistula. But if imaging is negative then Combined bronchoscopy and esophagoscopy may help.
http://emedicine.medscape.com/article/414368-overview#a19
Says that contrast esophagogram is study of choice. But it is known to miss the diagnosis. The following article says what to do if it fails.
Now : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675298/ “H-type Tracheoesophageal fistula” M M Harjai, et al state
Congenital isolated TEF (H‐type) is a rare disorder posing diagnostic and management problems.1 N‐type TEF is more frequent than H‐type, owing to the oblique angle of the fistula from the trachea (carina or main bronchi) to the oesophagus, anatomically at the level of the neck root (C7–T1). Pressure changes between both structures can cause entry of air into the oesophagus, or entry of oesophageal content into the trachea. Clinical manifestations—cyanosis, cough and choking with feeding, recurrent chest infections and persistent gastrointestinal distension—are related to the presence of the fistulous connection. Diagnosis is confirmed with oesophagogram or an video‐oesophagogram. In our case, the oesophagogram was so clear that we were prompted to report it. Failure to identify an H‐type TEF, an unsatisfactory radiological method and similar symptoms related to associated anomalies may cause delay in diagnosis and lead to fatality. If there is a doubt about the radiograph, bronchoscopy and simultaneous administration of methylene blue should be the next diagnostic step. Any delay in surgery is generally due to delay in diagnosis rather than delay in presentation.
Thus though a Xray or a Contrast esophagogram may be the 1st diagnostic test done, if it misses the diagnosis, a Bronchoscopy with simultaneous oral administration of methylene blue dye will help clinch the diagnosis. It would be like direct visualization of methylene blue trickling into trachea from esophagus, thus proving the existence of a H type fistulas.
Hence the best answer here should be A. Tracheo-Bronchoscopy.
3. Anorchia best diagnosed by?
A. USG
B. SPECT
C. CT
D. Laparoscopy
3. Ans D. Laparoscopy
REF :
http://www.urology-textbook.com/anorchia.html
https://www.cornellurology.com/clinical-conditions/pediatric-urology/cryptorchidism/
Bilateral Anorchia: Vanishing Testis Syndrome
Definition of the Vanishing Testis Syndrome
Bilateral anorchia or the vanishing testis syndrome is a loss of testicular function during fetal development. It leads, depending on the time of the damage, to more or less pronounced male pseudohermaphroditism. The maximum variation is the loss of testicular function before the 8th week of fetal development, with female differentiation of the internal and external sex organs. The minimal variation is the male newborns with normal genitalia, but without detectable testicular function (after HCG stimulation).
Diagnosis of the Vanishing Testis Syndrome
The determination of the testosterone concentration before and after HCG stimulation does not show an adequate increase. Determination of Anti-Müllerian hormone (low) and inhibin (low). Diagnostic laparoscopy confirms the absence of testicular tissue (McEachern, 2004).
Treatment of Bilateral Anorchia
Normally, the patient is assigned to the male gender role with lifelong testosterone replacement treatment.
Generally radiologic imaging is not reliable. Ultrasound can help identify a testicle located in the inguinal canal, but is of limited use for intrabdominal testes. MRI and CT scan can be useful for intrabdominal testes, but they are often difficult to use on small children and have a high rate of false negative results.
Laparoscopy can be used to localize nonpalpable, undescended testes. The laparoscopy is performed first to find out if the testicle is located in the abdomen or if it is congenitally absent.
If the testis is low in the abdomen, an orchidopexy is performed laparoscopically. A laparoscope is inserted through a small umbilical opening to locate the non-palpable testis. If the testis is healthy, a second instrument is placed through a small opening in the scrotum to move the testicle into its natural postion. Sometimes the testicle is located too high in the abdominal cavity to reach in a one step operation. In this setting, the testicle will be freed of it previous blood supply and placed in a location such that it can be brought down with a second operation. The second stage is performed in 6 months.
4. Lactating women with painful breast, 1st investigation to be done should be?
A. USG.
B. Mammography
C. CT
D. MRI
Ans A. USG
REF :
1. Can a Lactating Woman Have a Mammogram? Patricia (Pat) A. Camillo, PhD http://www.medscape.com/viewarticle/449395
2. Accuracy of Diagnostic Mammography and Breast Ultrasound During Pregnancy and Lactation. Read More: http://www.ajronline.org/doi/full/10.2214/AJR.09.3662
A mammogram is not the best diagnostic tool for a lactating woman for the same reasons that it is not generally recommended for most women under age 35 years. Young women tend to have very dense breasts, making it difficult to find radiographic lesions. The lactating breast shows an even greater increase in parenchymal density, with more nodular and rope-like characteristics, corresponding to ductal distention with milk.
Here is an alternative approach to consider for lactating women with suspected lesions[1]:
Begin with an ultrasound if there is a palpable abnormality. Ultrasound can clearly demonstrate a solid vs cystic mass or galactocele. This would initially eliminate the need for a mammogram.
* Fine-needle aspiration can be offered if a mass is determined to be a cyst or galactocele, usually with no further intervention necessary.
* If the palpable mass appears solid on ultrasound, a biopsy is indicated. Stereotactic guidance for fine-needle aspiration or large-core breast biopsy can be used successfully in the lactating woman. To minimize creation of a milk fistula, the affected breast should be pumped just prior to the procedure.
* Biopsy is also indicated if the mass is palpable but the ultrasound is negative.
* If the abnormality is found to be malignant, then a bilateral mammogram is done, the purpose of which is to explore whether there are other suspicious lesions.
Fortunately, breast cancers are not common in lactating women. Lactating adenomas and fibroadenomas are the most common solid palpable masses and these are always benign. However, when malignancies are found, they are often in an advanced stage with a poor prognosis. This has less to do with the physiology of these lesions and more to do with the delay in identifying them.[3] Although routine mammography screening is not indicated, a baseline clinical breast examination is an important part of initial prenatal care. Changes or abnormalities of any kind should be investigated with the same level of concern regardless of whether a woman is breast-feeding.
The National Comprehensive Cancer Network's guidelines of first using breast ultrasound followed by mammography when the sonographic findings are inconclusive or suspicious in the evaluation of nonpregnant symptomatic women younger than 30 years appears to be an appropriate approach to the evaluation of symptomatic pregnant or lactating women
CT is very rarely used in breast imaging. MRI is used as a problem solving modality when USG / Mammography fails to give a definitive diagnosis. Hence if the 1st investigation in a lactating female is the question asked, USG should be the best option.
5. Radiologically, increased pulmonary blood flow is indicated by the following except:
A. Descending pulmonary artery diameter> 16 mm
B. Kerley b lines
C. Diameter of 2 peripheral arteries > accompanying bronchiole
D. > 6 blood vessel in outer 1/3rd
5. Ans C. > None of the above
After a extensive search in Radiology literature including Sutton, Grainger, Felson, e-medicine, AJR and RSNA the closest reference I found was the following:
SPM
1.Regarding ESI ACT WHICH IS CORRECT
A)Funeral benefit is Rs 50000
b) The State Government’s share of expenditure on medical care is 1/8 ; the ESI Corporation’s share of expenditure on medical care is 7/8 of total cost
C)Person with daily wages of Rs 70 has to contribute Rs 300 towards ESI
d)Employee has to contribute 4.75% and employer contributes 8.75%
ans b
The Employees State Insurance Act, 1948(REF-OHC BOOK PAGE 452)
FINANCE
* The scheme is run by contributions by employees and employers and grants from Central and State Governments.
* The employer contributes 4.75 % of total wage bill; the employee contributes 1.75 % of wages.
* The State Government’s share of expenditure on medical care is 1/8 of total cost of medical care; the ESI Corporation’s share of expenditure on medical care is 7/8 of total cost of medical care.
Maternity benefit
* For confinement, the duration of benefit is 12 weeks (84 days), for miscarriage 6 weeks.
* The benefit is allowed at about full wages.
Disablement benefit
* The rate of temporary disblement benefit is about 70 % of the wages.
Dependant’s benefit
* Pension at the rate of 70 % of wages is payable.
* An eligible son or daughter is entitled to dependant’s benefit up to the age of 18; the benefit is withdrawn if the daughter marries earlier.
Funeral expenses
* Amount not exceeding Rs. 5000.
2. In assessing the literacy rate the parameter which is utilized(AIIMS NOV-2013)
a)age above 7 years
b)schooling upto 10th class
c)schooling upto 15years
d)all population
ans A
Literacy and education
* A person is deemed as literate if he or she can read and write with understanding in any language. A person who can merely read but cannot write is not considered literate.
* The literacy rate taking in account the total population in the denominator has now been termed as “crude literacy rate”, while the literacy rate calculated taking into account the 7 years and above population in the denominator is called the effective literacy rate.
Percentage of literates – 74.04***
* The national percentage of literates in the population above 7 years of age is about 74.04 males about 82.14% and females 65.46%.
* Kerala - 93.91% literates.
3. What is true regarding Polio
a)India is the only country which could not eradicate polio
b)last case was reported in JAN 13 2011(WILD POLIO)
c)India is currently using IPV
d)Vaccine borne case in 2012
* India has been considered polio-free since February 2012.
* As of 25th February 2012, India was removed from the list of polio endemic countries by the WHO.
* It has to remain polio free for another 2 years to achieve the goal of polio eradication.
4. Regarding disaster management high priority is given for AIIMS NOV-2013)
a)Green
b)Red
c)Black
d)yellow
ans b
Disaster impact and response
Triage
* The principle of “first come, first treated”, is not followed in mass emergencies. Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelyhood of their survival with prompt medical intervention.
* Triage is the only approach that can provide. maximum benefit to the greatest number of injured in a major disaster situation.
* The most common classification uses the internationally accepted four colour code system.
* Red indicates high priority treatment or transfer, yellow signals medium priority, green indicates ambulatory patients and black for dead or moribund patients.
5. Screw feed technology-all except(AIIMS NOV-2013)
A)NON BURN
B)VOLUME reduction more than 50%
c)weight reduction 20-35%
d)ideal for pathological waste
ans d
A non-burn, dry thermal disinfection process in which waste is shredded and heated in a rotating auger.
* Waste is reduced by 80% in volume and by 20-35 % in weight.
* This process is suitable for treating infectious waste and sharps.
6. % of GDP allotted to health in India(AIIMS NOV 2013)
a).12
b).012
c)0.5
d)0.05
ANS B
7. Burden of under 5 mortality in the world in 2010 is
a)6 million
b)8 million
c)10 million
d)12 million
ANS D(7.6 MILLION)
8.Regarding measles vaccination strategy in 9-14 yrs is called as
a)Catch up
b)keep up
c)mop up
d)follow up
ans A
9.Immunisation of 5 year old by NIS
a)pentavalent vaccine –Vitamin A
b)booster DT
c)DT,OPV,Vitamin A
d)DPT ,Vitamin A
ANS C
[10]True regarding Q test
a) comparing the proportion of means of 2 groups
b)to determine outliars
c)to determine normality distribution
d) comparing the proportion of means of MORE THAN 2 groups
ans b
[11]Indoor air pollution will cause all except
A)adverse pregnancy outcome
b)neurological complications
c)child pneumonia
d)chronic lung disease
ans B
Indoor air pollution
Monitoring of air pollution
* The best indicators of air pollution are sulphur dioxide, smoke and suspended particies.
a. Sulphur dioxide:
b. Smoke or soiling index:(1992-JIP***).
* A known volume of air is filtered through a white filter paper.
* Smoke concetration is estimated and expressed as micrograms/cubic metre of air.
c. Grit and dust measurement.
d. Coefficient of haze.
e. Air pollution index.
Health aspects
Major air pollutants, their sources and adverse effects
Respiratory tract irritation, bronchial hyperactivity, impaired lung defences, bronchiolitis obliterans
Lung cancer
Cough, substernal discomfort, bronchoconstriction, decreased exercise performance, respiratory tract irritation
Exacerbation of asthma and COPD, respiratory tract irritation, hospitalization may be necessary, and death may occur in severe exposure
OUTDOOR air pollution
Lead Automobile exhaust using leaded gasoline Impaired neuropsychological development in children
[12]ROLL BACK MALARIA-all except
a)strengthening health system
b)insecticide treated bed nets
c)development of insecticides
d)training health personal
and c)
[13]MEAN IN HB of 2000 population is 13.5 gm.How much proportion of patients are above mean
a)o.5%
b)0.25
c)0.75
d)0.1
ans a
[14]The % of people lying between mean and mean + 1.standard deviation
a)0.68
b)0.34
c)o.12
d)0.15
ans b
True about pterygium
1.exposure to infra red rays
2.probe can be passed underneath the pterygium at the limbus
3.elastic degeneration in the descemets membrane
4.resection via bare sclera technique cause recurrence of 30-70%
Ans d
*bare sclera technique had a recurrence rate of 66.7%. (NET)
*Ultra violet rays may cause
*elastotic degeneration of conjunctiva
Stocker’s line - presence of a pigment line in front of the pterygium , suggestive of long standing non-progressive pterygium.
SURGICAL
1. Excision with simple closure of the wound.
2. Mc Gavics bare sclera method:
• pterygium is excised and the conjunctival defect is left as it is.
• High rates of recurrence and granuloma formation .
3. Transplantation of the pterygium : Pterygium excision with auto-conjunctival graft / amniotic membrane graft. Done in recurrent pterygium / large pterygium.
4. Mac Reynold’s operation: head is sutured to the body itself.
5. Kehr’s operation: head is sutured to the inferior fornix.
Most common type of NHL Worldwide(AIIMS NOV 2013)
a)Diffuse large B cell lymphoma
b)Follicular lymphoma
c)Small cell lymphoma
d)Diffuse small lymphocytic lymphoma
Diffuse Large B Cell Lymphoma
* Most common type of non-Hodgkin's lymphoma.*
* Cytogenetic and molecular genetic studies are not necessary for diagnosis.
* Primary mediastinal diffuse large B cell lymphoma- younger median age (i.e., 37 years) and a female predominance .
* Neoplastic cells are heterogeneous but predominantly large cells with vesicular chromatin and prominent nucleoli.
* More than 50% of patients will have extranodal involvement at diagnosis, with the most common sites being the gastrointestinal tract and bone marrow.
* Other unusual subtypes of diffuse large B cell lymphoma such as pleural effusion lymphoma(AI-2006***) and intravascular lymphoma - very poor prognosis.
Follicular Lymphoma
*Females
22% of non-Hodgkin's lymphomas
*Treatment-one of the malignancies most responsive to chemotherapy and radiotherapy-25% of the patients undergo spontaneous regression
Which is false with regarding megaloblastic anemia (AIIMS NOV-2013)(AIIMS NOV 2012 RPT)
a)reticulocyte increased
b)nucleated RBCs
c) increased bilirubin
d)mild splenomegaly
ans a
MEGALOBLASTIC ANEMIA
MCV > 100 FL
* WBC, Platelets ¯
* PS – Anisopioiklocytosis, macrocytosis
* Low retic index(AIIMS NOV-2012***)
* Basophillic stippling (in RBC), normoblast
* Neutrophils – Hypersegmentation of nucleus (characteristic)
* Bone marrow
- Hyper cellular
- ¯ myeloid/erythroid ratio
- Abundant iron
- Nuclear chromatin – a peculiar fenestrated pattern very characteristic
- ¯ megakaryocytes
* LDH, bilirubin
* Cobalamin level
- 160-200ng/ml
- < 100 – deficiency
* Folate level – 6-20 micro/ml < 4 microg – deficiency
• Ineffective Hemopoiesis
• * Unconjugated bilirubin , raised urine urobilinogen, reduced haptoglobins and positive urine hemosiderin, and a raised serum lactate dehydrogenase&a weakly positive direct antiglobulin test
All are true about Fe def anemia except (AIIMS NOV 2013)
A. Transferrin saturation <16 p="">B. Is detected by serum ferritin levels even in earlier states
C. Is mostly presented without any symptoms
D. Latent anemia is most prevalent in india
ANS A
Iron deficiency Anemia
3 Stages
Negative iron balance - Iron stores are decreased, ferritin Decreased
- All other paramaters – normal
Parameter Normal IDA
*Sr.Iron(microgm/dl) 50-150 <30 p="">*Sr.Ferritin(microgm/dl) 50-200 <15 p="">*TIBC 300-360 >400
* TSAT 30-50 <10 p="">
Which of the following is not a cause of acquired pure red cell aplasia
A)ABO incompatability in BMT
b)Drug induced-NSAIDS
c)5Q-MONOSOMY
D)LYMPHOMA
ANS B
In adults, PRCA is acquired.
* Immunologic-Systemic lupus erythematosus, juvenile rheumatoid arthritis, rheumatoid arthritis.
* Virus-Persistent B19 parvovirus, hepatitis, adult T cell leukemia virus, Epstein-Barr virus.
* Drugs-phenytoin, azathioprine, chloramphenicol, procainamide, isoniazid, Erythropoietin.*
* Parvo virus B19
Lymphoma
REF-NET
• Thymoma (1-15%)
• Hematological malignancies (eg, B- and T-cell chronic lymphocytic leukemia)
• T-cell large granular lymphocyte leukemia and solid tumors
• Infections
• Drugs
• Pregnancy[7]
• Systemic lupus erythematosus
• Renal failure
• Good syndrome (thymoma with combined B- and T-cell deficiency)
PRCA can occur following ABO mismatched marrow transplantation
WHICH IS NOT TRUE REGARDING hemoptysis
a) massive hemoptysis is more than 600ml/24 hrs
b) 90% bleed from bronchial artery
c) CT chest is done as the 1st investigation
d) In an unstable patient rigid bronchoscope is done to identify the lesion
Ans a
The most common etiology of hemoptysis is infection of the medium-sized airways.
* Massive hemoptysis - greater than 200–600 cc in 24 h
Fiberoptic bronchoscopy is particularly useful for localizing the site of bleeding and for visualization of endobronchial lesions. When bleeding is massive, rigid bronchoscopy is often preferable.
* In patients with suspected bronchiectasis, HRCT is the diagnostic procedure of choice.
Massive hemoptysis - >100–600 mL over a 24-h period(17thEDITION)
Hemoptysis: Treatment
* Selectively intubating the nonbleeding lung. (often with bronchoscopic guidance)
* Other available techniques - laser phototherapy, electrocautery, bronchial artery embolization, and surgical resection of the involved area of lung.
* With bleeding from an endobronchial tumor- argon plasma coagulation or the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
* Bronchial artery embolization - a vessel proximal to the bleeding site is cannulated, and Gelfoam is injected to occlude the bleeding vessel.
REF-JOURNAL
Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review.
*Massive hemoptysis is one of the most dreaded of all respiratory emergencies and can have a variety of underlying causes.
* In 90% of cases, the source of massive hemoptysis is the bronchial circulation. ***
*Diagnostic studies for massive hemoptysis include radiography, bronchoscopy, and computed tomography (CT) of the chest.***
*. Many researchers currently suggest that CT should be performed prior to bronchoscopy in all cases of massive hemoptysis.
* Bronchial artery embolization (BAE) is a safe and effective nonsurgical treatment for patients with massive hemoptysis.
MEDICINE
1. A Lady brought her husband to the casuality.Patient is an alcohoholic who not consumed alchol for 2 days for religious reasons. Developed nausea vomiting on day 1 and day 2 developed seizures.What is the most likely treatment (AIIMS NOV-2013) (AIIMS MAY 2013 RPT)[/b]
a) Diazepam
b) Sodium valproate
c) Phenytoin
d) clonidine
Ans a
Ref-Consultant-POZITIVE Psychiatry hand out-page44, 18
• Most severe Alcohol withdrawal syndrome
• Within 2-4 days of abstinence
• in 5%
• Recovers within 3-7 days
• An acute organic brain syndrome
Features
• Clouding of consciousness
• Poor attention span
Hallucinations
• Visual (common)
• Auditory
• Tactile
• Autonomic disturbance
• Psychomotor agitation and ataxia
Drug of Choice
• Benzodiazepines
• Chlordiazepoxide or Diazepam
2. In glassgow coma scale withdrawal to pain stimulus comes under ( AIIMS NOV-2013)
a) M4
b) M3
c) M2
d) M5
ans-A
3 True about Kluver bucy syndrome are all expect: (AIIMS NOV-2013)
a. hypersexuality
b. hypermetamorphosis
c. hyperactivity
d. Placidity
Ans c
Kluver Bucy syndrome- (Bilat medial temporal destruction) – hyperorality, hypersexuality, hypermetamorphosis, placidity, Visual Agnosia
Kluver Bucy syndrome in young children. All except [AIIMS MAY 2013]
A) hypermetamorphosis
B) Hypersexuality
C) visual agnosia
D) refractory seizures
Ans (d)
4) All are true regarding METHANOL poisoning except
a) critical level is 1.25
b) fomipazole-inhibits with aldehyde dehydrogenase
c) Formic acid is responsible for toxicity
d) snowfield vision is seen in Methyl alcohol poisoning
ans b
Methanol
* The ingestion of methanol (wood alcohol) causes metabolic acidosis, and its metabolites formaldehyde and formic acid cause severe optic nerve and central nervous system damage.
Treatment- saline or osmotic diuresis, thiamine and pyridoxine supplements, fomepizole or ethanol, and hemodialysis - alcohol dehydrogenase inhibitor fomepizole (4-methylpyrazole).
* Posm = 2Na+ + Glu/18 + BUN/2.8.
* When the measured osmolality exceeds the calculated osmolality by >15–20 mmol/kg H2O, one of two circumstances prevails. Either the serum sodium is spuriously low, as with hyperlipidemia or hyperproteinemia (pseudohyponatremia), or osmolytes other than sodium salts, glucose, or urea have accumulated in plasma. Examples include mannitol, radiocontrast media, isopropyl alcohol, ethylene glycol, propylene glycol, ethanol, methanol, and acetone.
* Three alcohols may cause fatal intoxications: ethylene glycol, methanol, and isopropyl alcohol. All cause an elevated osmolal gap, but only the first two cause a high-AG acidosis.
Ethylene Glycol
* Ingestion of ethylene glycol (commonly used in antifreeze) leads to a metabolic acidosis and severe damage to the central nervous system, heart, lungs, and kidneys.
* Diagnosis is by recognizing oxalate crystals in the urine, the presence of an osmolar gap in serum, and a high-AG acidosis. If antifreeze containing a fluorescent dye is ingested, a Wood's lamp applied to the urine may be revealing.
* Treatment- similar to that for methyl alcohol
5 Recently approved by FDA for treatment of lennox- gestaut SYNDROME (AIIMS NOV2013)
A. lacosamide
B. rufinamide
C. zonisamide
D. levetiracetam
And b
Rufinamide used in Lennox-Gastaut syndrome
* Side effects
* Sedation
* Fatigue
* Dizziness
* Ataxia
* Headache
* Diplopia,(QT interval prolongation)
* Rufinamide-interactions
* Level increased by valproic acid
* May increase phenytoin
Uniparenral disomy not seen in ]
a. Bloom syndrome
b. Angelman syndrome
c. Silver Russell syndrome
d. Prader willi syndrome
ans a
Genomic imprinting- Two classic examples are the Prader-Willi syndrome and Angelman syndrome.
* Prader-Willi syndrome(AIIMS-NOV-2010***) - characterized by diminished fetal activity, obesity, hypotonia, mental retardation, short stature, and hypogonadotropic hypogonadism. Deletions of the paternal copy of the Prader-Willi locus located on the short arm of chromosome 15 result in a contiguous gene syndrome involving missing paternal copies of the necdin and SNRPN genes.
* Angelman syndrome- characterized by mental retardation, seizures, ataxia, and hypotonia, have deletions involving the maternal copy of this region on chromosome 15.
* These two syndromes may also result from uniparental disomy. In this case, the syndromes are not caused by deletions on chromosome 15 but by the inheritance of either two maternal chromosomes (Prader-Willi syndrome(AIIMS-NOV-2010***)) or two paternal chromosomes (Angelman syndrome).
*Defective DNA repair-Fanconi’s, Bloom’s, Ataxia Telengiectasia
Severe malaria all except
a) Hypoglycemia –less than 40mg
b) creatinine more than 3mg
c) LDH more than 45
d) Hct more than 15
ans D
Indicating a Poor Prognosis in Severe Falciparum Malaria
Hypoglycemia Leukocytosis >20% of parasites identified as pigment-containing trophozoites and schizonts
Hyperlactatemia Severe anemia, >5% of neutrophils with visible pigment
Acidosis Coagulopathy
Elevated serum creatinine
Elevated total bilirubin,enzymes
Elevated urate
A female with excess consumption of junk food presented with gum bleed, echymosis, hemarthrosis and perifollicular bleeds-Problem lies with(AIIMS NOV2013)
a) glumate carboxylation
b) carboxylation of coagulation factors
c) Hydroxylation of proline and lysine
d)
ans a
VIT-C
Functions-antioxidant activity, promotion of nonheme iron absorption, carnitine biosynthesis, the conversion of dopamine to norepinephrine.
* good dietary sources of vitamin C include citrus fruits, green vegetables.
* smoking, hemodialysis, pregnancy, and stress appear to increase vitamin C requirements.
* vitamin C deficiency causes scurvy- (petechiae, ecchymoses, perifollicular hemorrhages ); inflamed and bleeding gums; - In children, vitamin C deficiency may cause impaired bone growth.
* laboratory diagnosis of vitamin C deficiency is made by low plasma or leukocyte levels.
* useful in Chédiak-Higashi syndrome and osteogenesis imperfecta .
* lower the incidence of certain cancers, particularly esophageal and gastric cancers.
* toxicity-?kidney stones, promote iron overload in patients taking supplemental iron , hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency, false-negative guaiac reactions as well as interfere with tests for urinary glucose.
45 year old lady presents with painless supraclavicular lymphadenopathy.Biopsy revealed binucleated acidophilic owl eye appearance with floating lymphocytes in empty space which was CD 15,CD 30 positive.The probable diagnosis
a) Nodular sclerosing lymphoma
b) lymphocyte predominant lymphoma
c) Anaplastic large cell lymphoma
d)
ansA
30 yr old with hirsutism,infertility and obesity- diagnosed to be PCOS .what is the NOT the treatment option
a) Oral contraceptive pills
b) Tamoxifen
c) clomiphene citrate
d) spironolactone
ANS b
Polycystic Ovarian Syndrome (PCOS)(AI-2011***)
* Hyperandrogenism in association with amenorrhea or oligomenorrhea.
* Lean patients with PCOS generally have high LH levels in the presence of normal to low levels of FSH(elevated LH/FSH ratio) and estradiol.
* The LH/FSH abnormality is less pronounced in obese patients in whom insulin resistance is a more prominent feature.
Treatment
* These patients are at risk for the development of dysfunctional bleeding and endometrial hyperplasia.
* Endometrial protection can be achieved with the use of oral contraceptives or progestins (medroxyprogesterone acetate prometrium).
* Spironolactone, which functions as a weak androgen receptor antagonist.
* Clomiphene citrate is highly effective as first-line treatment, with or without the addition of metformin.
Fertilised ovum reaches the uterine cavity by :-
A. 6-7 days
B. 5- 6
C. 7-8
D. 4-5 days
ANS –D
‘0’hour – Fertilization (D-15 from LMP)
30 hrs – 2 cell stage (Blastomeres)
40-50 hrs – 12 cell stage
72 hrs – 12 cell stage
96 hrs – 16 cell stage. Morula enters the uterine cavity(AIIMS NOV-2013***)
5th day – Blastocyst
All are physiological changes during pregnancy except
a) distended neck veins
b) systemic hypotension
c) pedal edema
d) dyspnoea
ANS B
REF-POSIGOLD-AIIMS NOV-2012 [/b]
Blood testis barrier is between
a. Sertoli and sertoli cells
b. Leydig and myoid cells
c. Sertoli and germ cells
d. Sertoli and spermatid
ans a
Blood–Testis Barrier-Tight junctions between adjacent Sertoli cells near the basal lamina form a blood–testis barrier that prevents many large molecules from passing from the interstitial tissue and the part of the tubule near the basal lamina (basal compartment) to the region near the tubular lumen (adluminal compartment) and the lumen.
* The fluid in the lumen of the seminiferous tubules is quite different from plasma; it contains very little protein and glucose but is rich in androgens, estrogens, K+, inositol, and glutamic and aspartic acids.
Long collagen fibres with wide spacing between them found in (AIIMS NOV2013)
A.cornea
B.tympanic membrane
C.basement membrane
D.diaphragm
ANS A
• Corneal Stroma
• - occupies about 90% of the total corneal thickness, is composed of collagen fibrils, keratocytes and extracellular ground substances.
• - Collagen fibers are highly uniform in diameter (25-35 nm) .
• -The distance between two corneal fibers is also highly uniform (41.5nm) .Corneal transparency is mainly dependent on the arrangement of these collagen fibers in stroma.
• - It is continuous with the sclera and limbus.
Cause of corneal transparency:
1. Anatomical factors:
a. Cornea does not contain opaque structures:
- No keratin in the epithelium.
- No blood vessels.
- No myelin sheath around nerve fibers.
b. Regular arrangement of collagenous bundles in the stroma.
c. Smooth anterior surface.
2. Physical factors:
- The spacing between the collagenous fibrils is uniform and less than half the wavelength of visible light (400-700 nm). So that the scattered light rays destroy each other allowing clear vision.
3. Physiological factors - (deturgescence of the cornea):
The External anal sphincter is supplied by
A) S2,S3,S4
B) S2,S3
C) L5,S1
D) S1,S2
Ans a
Transit Time in the Small Intestine & Colon
* The first part of a test meal reaches the cecum in about 4 h, and all the undigested portions have entered the colon in 8 or 9 h.
* Defecation- the sympathetic nerve supply to the internal (involuntary) anal sphincter is excitatory, whereas the parasympathetic supply is inhibitory.
* The nerve supply to the external anal sphincter, a skeletal muscle, comes from the pudendal nerve. (AIIMS NOV-2013***)
* The urge to defecate first occurs when rectal pressure increases to about 18 mm Hg.
* When this pressure reaches 55 mm Hg, the external as well as the internal sphincter relaxes and there is reflex expulsion of the contents of the rectum.
* Distention of the stomach by food initiates contractions of the rectum and, frequently, a desire to defecate. The response is called the gastrocolic reflex, and may be amplified by an action of gastrin.
Percentage of death in emergency AAA operation
a) 40%
b) 10%
c) 5%
d) 1-2%
Ans a
REF-POSIGOLD
Aortic aneurysm
Operative repair with placement of a prosthetic graft is indicated in patients with symptomatic thoracic aortic aneurysms, those in whom the ascending aortic diameter is >5.5–6 cm or the descending thoracic aortic diameter is >6.5-7 cm, and those with an aneurysm that has increased by >1 cm per year.
In patients with Marfan syndrome or bicuspid aortic valve, ascending thoracic aortic aneurysms >5 cm should be considered for surgery.
Abdominal Aortic Aneurysms
Abdominal aortic aneurysms occur more frequently in males
At least 90% of all abdominal aortic aneurysms - below the level of the renal arteries.
The risk of rupture increases with the size of the aneurysm: the 5-year risk for aneurysms <5 1="" 20="" aneurysms="" cm="" for="" is="" it="" whereas="">5 cm in diameter.
With careful preoperative cardiac evaluation and postoperative care, the operative mortality rate approximates 1–2%.
After acute rupture, the mortality rate of emergent operation is 45–50%
The ability of the body to eliminate the drug is called as
a) rate of elimination
b) clearance
c) steady state
d) volume of distribution
ANS B
REF-OH Book-page-11
Clearance
* Includes both metabolism and excretion.
* For a drug administered as an IV infusion
Which of the following is false regarding treatment of osteoporosis
a) IV PTH is the treatment for severe osteoporosis
b) calcitonin decreases bone pain
c) Bisphonates are work horse for treatment
d) T score 1.5 indicates osteopenia
ANS D
• Endogenous PTH is an 84-amino-acid peptide that is largely responsible for calcium homeostasis
• Although chronic elevation of PTH, as occurs in hyperparathyroidism, is associated with bone loss (particularly cortical bone), PTH also can exert anabolic effects on bone
• exogenous PTH analogue (1-34hPTH; teriparatide) that has been approved for the treatment of established osteoporosis in both men and women.
• Calcitonin might have an analgesic activity***
• Calcitonin suppresses osteoclast activity by direct action on the osteoclast calcitonin receptor
•
Measurement of Bone Mass
• dual-energy x-ray absorptiometry (DXA),
• single-energy x-ray absorptiometry (SXA),
• quantitative CT,
• ultrasound (US).
• T-scores, which compare individual results to those in a young population that is matched for race and sex.
• Z-scores compare individual results to those of an age-matched population that also is matched for race and sex.
• A T-score below –2.5 in the lumbar spine, femoral neck, or total hip is taken as a diagnosis of osteoporosis
•
• Risedronate and alendronate are approved for the treatment of steroid-induced osteoporosis, and
• risedronate also is approved for prevention of steroid-induced osteoporosis.
• Both alendronate and risedronate are approved for treatment of osteoporosis in men.
•
Osteopenia-T – Score-< - 1 & >-2.5
Platelet adhesion to collagen via
a. F viii
b. Fix
c. VWF
d. Fibronectin
ans c
Platelet Adhesion
* Certain proteins are expressed on the platelet surface that subsequently regulate collagen-induced platelet adhesion, particularly under flow conditions, and include glycoprotein (GP) IV, GPVI, and the integrin alfa 2, beta 1.
* The GPIb-IX-V complex binds to the exposed von Willebrand factor, causing platelets to adhere
* Von Willebrand factor–bound GPIb-IX-V promotes a calcium-dependent conformational change in the GPIIb/IIIa receptor, transforming it from an inactive low-affinity state to an active high-affinity receptor for fibrinogen.
Factors that promote platelet aggregation :
• ADP
• Epinephrine
• TXA2
• Serotonin
• vWF
• Fibrinogen
• Thrombospondin
• collagen
• Immune complex
• Thrombin
[/bThe ability of the body to eliminate the drug is called as (AIIMS NOV2013)[/b]
a) rate of elimination
b) clearance
c) steady state
d) volume of distribution
ANS B
Compared to unfractionated heparin,LMWH has reliable anticoagulant action because
A) it interferes with thrombin and antithrombin III simultaneously
b) It is less protein bound
c) It is given subcutaneously
d) It is cleared by macrophages
ans b
HEPARIN
Clearance
* Includes both metabolism and excretion.
* For a drug administered as an IV infusion
Dose-dependent clearance- due to Binding to macrophages.
* Activated platelets release platelet factor 4 (PF4), a highly cationic protein that binds heparin with high affinity.
* Monitored by APTT, or anti-factor Xa level.
* Heparin resistant- require >35,000 units/d to achieve a therapeutic aPTT.
* Dissociation- many will have a therapeutic anti-factor Xa level despite a subtherapeutic aPTT- patients who exhibit this phenomenon is best monitored using anti-factor Xa levels instead of the aPTT.***
* Side Effects- thrombocytopenia, osteoporosis(30%), and elevated levels of transaminases. Symptomatic vertebral fractures occur in 2–3%.
* Heparin affects the activity of both osteoblasts and osteoclasts.
* 1 mg of protamine sulfate neutralizes 100 units of heparin.
Low-Molecular-Weight Heparin
* Prepared from unfractionated heparin by controlled enzymatic or chemical depolymerization-molecular weight of LMWH is 5000.
LMWH catalyzes factor Xa inhibition by antithrombin.
* Bind less avidly to endothelial cells, macrophages, and heparin-binding plasma proteins.(AIIMS NOV-2013)
* Plasma half-life of ~4 h- cleared almost exclusively by the kidneys.
* 90% bioavailability after SC injection.
* Does not require coagulation monitoring. If monitoring is necessary, anti-factor Xa levels must be measured.***
Insulin :glucagon ratio is low favouring wich enzyme? (AIIMS NOV-2013)
a. Pyruvate kinase
b. glucokinase
c. hexokinase
d. glucose 6phosphatase
ans d
Insulin
Protein Metabolism
* The supply of amino acids is increased for gluconeogenesis because, in the absence of insulin, less protein synthesis occurs in muscle and hence blood amino acid levels rise.
* Alanine is particularly easily converted to glucose.
* The activity of the enzymes increased- phosphoenolpyruvate carboxykinase, which facilitates the conversion of oxaloacetate to phosphoenolpyruvate ;also include fructose 1,6-diphosphatase, which catalyzes the conversion of fructose diphosphate to fructose 6-phosphate, and glucose 6-phosphatase,
Insulin–Glucagon Molar Ratios
* Insulin is glycogenic, antigluconeogenetic, antilipolytic, and antiketotic - "hormone of energy storage."
* Glucagon- glycogenolytic, gluconeogenetic, lipolytic, and ketogenic. It mobilizes energy stores and is a "hormone of energy release."
*At low insulin glucagon ratio,gluconeogenesis is increased
Insulin–glucagon molar ratio
Situation Value
Balanced diet 2.3
Infusion of arginine 3.0
3 days of starvation 0.4
constant infusion of glucose 25
ingestion of a protein meal during the infusion 170
Trans cutaneoeus nerve stimulation to relieve pain acts by (AIIMS NOV2013)
a) Gate way theorey of pain
b) central pain
c) allodynia
d) Refered pain
ANS A
Stress-Induced Analgesia
* It is well known that soldiers wounded in the heat of battle often feel no pain until the battle is over (stress-induced analgesia).
* The relief may result from inhibition of pain pathways in the dorsal horn gate by stimulation of large-diameter touch-pressure afferents.
* Collaterals from these myelinated afferent fibers synapse in the dorsal horn. These collaterals may modify the input from nociceptive afferent terminals that also synapse in the dorsal horn. This is called the gate-control hypothesis.
Acupuncture at the site of the pain appears to act primarily in the same way as touching or shaking (gate-control mechanism).
Worker of asbestos factory with mass in the apical lobe .which is true regarding the HPE
1] Melanosomes
2] Desmosomes
3] neurosecretory granules
4] Tubular microvilli
Ans -2
Squamous cell carcinoma-Cells united by well-developed cell junctions (desmosomes), intercellular bridges, tonofilaments
a) IV PTH is the treatment for severe osteoporosis
b) calcitonin decreases bone pain
c) Bisphonates are work horse for treatment
d) T score 1.5 indicates osteopenia
ANS D
• Endogenous PTH is an 84-amino-acid peptide that is largely responsible for calcium homeostasis
• Although chronic elevation of PTH, as occurs in hyperparathyroidism, is associated with bone loss (particularly cortical bone), PTH also can exert anabolic effects on bone
• exogenous PTH analogue (1-34hPTH; teriparatide) that has been approved for the treatment of established osteoporosis in both men and women.
• Calcitonin might have an analgesic activity***
• Calcitonin suppresses osteoclast activity by direct action on the osteoclast calcitonin receptor
•
Measurement of Bone Mass
• dual-energy x-ray absorptiometry (DXA),
• single-energy x-ray absorptiometry (SXA),
• quantitative CT,
• ultrasound (US).
• T-scores, which compare individual results to those in a young population that is matched for race and sex.
• Z-scores compare individual results to those of an age-matched population that also is matched for race and sex.
• A T-score below –2.5 in the lumbar spine, femoral neck, or total hip is taken as a diagnosis of osteoporosis
•
• Risedronate and alendronate are approved for the treatment of steroid-induced osteoporosis, and
• risedronate also is approved for prevention of steroid-induced osteoporosis.
• Both alendronate and risedronate are approved for treatment of osteoporosis in men.
•
Osteopenia-T – Score-< - 1 & >-2.5
Platelet adhesion to collagen via
a. F viii
b. Fix
c. VWF
d. Fibronectin
ans c
Platelet Adhesion
* Certain proteins are expressed on the platelet surface that subsequently regulate collagen-induced platelet adhesion, particularly under flow conditions, and include glycoprotein (GP) IV, GPVI, and the integrin alfa 2, beta 1.
* The GPIb-IX-V complex binds to the exposed von Willebrand factor, causing platelets to adhere
* Von Willebrand factor–bound GPIb-IX-V promotes a calcium-dependent conformational change in the GPIIb/IIIa receptor, transforming it from an inactive low-affinity state to an active high-affinity receptor for fibrinogen.
Factors that promote platelet aggregation :
• ADP
• Epinephrine
• TXA2
• Serotonin
• vWF
• Fibrinogen
• Thrombospondin
• collagen
• Immune complex
• Thrombin
[/bThe ability of the body to eliminate the drug is called as (AIIMS NOV2013)[/b]
a) rate of elimination
b) clearance
c) steady state
d) volume of distribution
ANS B
Compared to unfractionated heparin,LMWH has reliable anticoagulant action because
A) it interferes with thrombin and antithrombin III simultaneously
b) It is less protein bound
c) It is given subcutaneously
d) It is cleared by macrophages
ans b
HEPARIN
Clearance
* Includes both metabolism and excretion.
* For a drug administered as an IV infusion
Dose-dependent clearance- due to Binding to macrophages.
* Activated platelets release platelet factor 4 (PF4), a highly cationic protein that binds heparin with high affinity.
* Monitored by APTT, or anti-factor Xa level.
* Heparin resistant- require >35,000 units/d to achieve a therapeutic aPTT.
* Dissociation- many will have a therapeutic anti-factor Xa level despite a subtherapeutic aPTT- patients who exhibit this phenomenon is best monitored using anti-factor Xa levels instead of the aPTT.***
* Side Effects- thrombocytopenia, osteoporosis(30%), and elevated levels of transaminases. Symptomatic vertebral fractures occur in 2–3%.
* Heparin affects the activity of both osteoblasts and osteoclasts.
* 1 mg of protamine sulfate neutralizes 100 units of heparin.
Low-Molecular-Weight Heparin
* Prepared from unfractionated heparin by controlled enzymatic or chemical depolymerization-molecular weight of LMWH is 5000.
LMWH catalyzes factor Xa inhibition by antithrombin.
* Bind less avidly to endothelial cells, macrophages, and heparin-binding plasma proteins.(AIIMS NOV-2013)
* Plasma half-life of ~4 h- cleared almost exclusively by the kidneys.
* 90% bioavailability after SC injection.
* Does not require coagulation monitoring. If monitoring is necessary, anti-factor Xa levels must be measured.***
Insulin :glucagon ratio is low favouring wich enzyme? (AIIMS NOV-2013)
a. Pyruvate kinase
b. glucokinase
c. hexokinase
d. glucose 6phosphatase
ans d
Insulin
Protein Metabolism
* The supply of amino acids is increased for gluconeogenesis because, in the absence of insulin, less protein synthesis occurs in muscle and hence blood amino acid levels rise.
* Alanine is particularly easily converted to glucose.
* The activity of the enzymes increased- phosphoenolpyruvate carboxykinase, which facilitates the conversion of oxaloacetate to phosphoenolpyruvate ;also include fructose 1,6-diphosphatase, which catalyzes the conversion of fructose diphosphate to fructose 6-phosphate, and glucose 6-phosphatase,
Insulin–Glucagon Molar Ratios
* Insulin is glycogenic, antigluconeogenetic, antilipolytic, and antiketotic - "hormone of energy storage."
* Glucagon- glycogenolytic, gluconeogenetic, lipolytic, and ketogenic. It mobilizes energy stores and is a "hormone of energy release."
*At low insulin glucagon ratio,gluconeogenesis is increased
Insulin–glucagon molar ratio
Situation Value
Balanced diet 2.3
Infusion of arginine 3.0
3 days of starvation 0.4
constant infusion of glucose 25
ingestion of a protein meal during the infusion 170
Trans cutaneoeus nerve stimulation to relieve pain acts by (AIIMS NOV2013)
a) Gate way theorey of pain
b) central pain
c) allodynia
d) Refered pain
ANS A
Stress-Induced Analgesia
* It is well known that soldiers wounded in the heat of battle often feel no pain until the battle is over (stress-induced analgesia).
* The relief may result from inhibition of pain pathways in the dorsal horn gate by stimulation of large-diameter touch-pressure afferents.
* Collaterals from these myelinated afferent fibers synapse in the dorsal horn. These collaterals may modify the input from nociceptive afferent terminals that also synapse in the dorsal horn. This is called the gate-control hypothesis.
Acupuncture at the site of the pain appears to act primarily in the same way as touching or shaking (gate-control mechanism).
Worker of asbestos factory with mass in the apical lobe .which is true regarding the HPE
1] Melanosomes
2] Desmosomes
3] neurosecretory granules
4] Tubular microvilli
Ans -2
Squamous cell carcinoma-Cells united by well-developed cell junctions (desmosomes), intercellular bridges, tonofilaments
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