SURGERY MCQ=aims may 2012

SURGERY MCQ=aims may 2012

 167. Not a Causes of acute anal pain:

a. Thrombosed hemorrhoids

b. Acute anal fissure

c. Fistula in ano

d. Perianal abccess

Answer : (c) Fistula in ano Reference: Harrison 18th edition/chapter 297, Bailey and love 26th edition,page 1263

168. 70 yr old man with prostate cancer was given radiotherapy. The recurrence of the cancer is monitored biochemically by

a. Androgens only

b. Prostate specific antigen and carcino-embryonic antigen

c. Prostate specific antigen only

d. ALP and CEA

Answer: (b) Prostate specific antigen and carcino-embryonic antigen Reference: NICE clinical guideline 58 – Prostate cancer (http://www.nice.org.uk/nicemedia/pdf/CG58NICEGuideline.pdf) and http://emedicine.medscape.com/article/1967731-treatment#a1156

169. A patient has a surgical cause of obstructive jaundice. USG can tell all of the following except

a. Level of obstruction

b. Peritioneal deposits

c. Gall bladder stones

d. Ascites

ANSWER (b) Peritioneal deposits Reference: A. Sutton Textbook of Radiology Volume 1 page 716 & 717 B. Biliary Obstruction Workup Imaging :guidelines/http://emedicine.medscape.com/article/187001-workup#a0720 C. Harrison 18th edition chapter 311/ table 311.3 Sutton says - In presence of biliary obstruction ultrasound is reported to define level in 95% and cause upto 88% of patients

170. Organism associated with fish consumption and also cause carcinoma gallbladder

a. Clonorchis sinensis

b. Gnathisomia

c. Anglostronglyoidosis cantonensis

d. H. dimunata

Answer  (a) Clonorchis sinensis [Reference: Harrison 17/e p1330; http//www.ncbi.nlm.nih.gov/pubmed/12483392 http://www.ncbi.nlm.nih.gov/pubmed/3993073]

171. Rupture of urethra above the deep perineal pouch causes urine retention in which region?

a. Medial aspect of thigh

b. Scrotum

c. True pelvis only

d. Anterior abdominal wall

Answer: (c) True pelvis only Reference: Smith Urology page 910

172. Ileal resection for intusussception in adults would be done in?

a. Carcinoid Tumor

b. Lymphoma

c. Villous adenoma

d. Soft tissue

Answer: C, Villous adenoma

Reference: Chapter 91 Harrison 18th Edition Intussusception of the bowel in adults: A review World J Gastroenterol. 2009 January 28; 15(4): 407–411 Pediatric Intussusception  surgery/http://emedicine.medscape.com/article/937730-overview#a0102

173. All are true about intestinal obstruction radio-graphically except

a. On lying supine fluid air gap absence does not signify obstruction

b. Volvulus shows a characteristic appearance on radiograph

c. Small intestine dilation> 3 cm

d. Distal large intestine >9 cm and proximal intestine>3 cm

Answer (d) Distal large intestine >9 cm and proximal intestine>3 cm

Reference: Oxford textbook of surgery Reference: Swartz’s 9e

174. Buerger disease all except are true

a. Ulnar artery and peroneal arteries involved

b. Neural involvement present

c. small acral vessels of limb involved

d. Phlebitis migrans

Answer (c) Small Acral vessels of limb small acral vessels of involvement causes hypohidrosis Reference: CMDT 2012 page 458 Vascular Disease: Diagnostic and Therapeutic Approaches By Michael R. Jaff Robbins textbook page 517 8th Edition

175. Next Investigation to be done for painful breast lump in a lactating woman

a. Mammography

b. USG

c. MRI

d. X Answer

(b) USG Reference: Breast Ultrasonography/http://emedicine.medscape.com/article/1948269-overview

176. Which of the following is not associated with elevation Right hemi-diaphragam:

a. Amebic abscess

b. Pyogenic abscess

c. Cholecystitis

d. Subdiaphragmatic abscess

Answer. (c) Cholecystis Reference: Green filed surgery page No: 910& 911

177. Not true of hernia is :

a. Conservative managment

b. In Child hernia treatment with herniotomy

c. Aborshable mesh not used

d. Long standing hernia increases changes of incarceration

Answer: D long standing hernia increases chances of incarceration Reference: chapter 343 ,Nelson textbook of Pediatrics 18th edition

178. Stereotactic radiotherapy is used for treatment of ?

a. Brain tumor

b. Lungs carcinoma

c. Cervix cancer

a. Renal carcinoma

Answer. (a>b) Reference: Neurology tumors of the brain and spine – M.D. Anderson cancer care series Page 136 Radiation Oncology for Tumors of the Central Nervous System Reference: http://www.cancerresearchuk.org/cancer-help/type/brain-tumour/treatment/radiotherapy/stereotactic-radiotherapy-for-brain-tumours Reference:http://www.rtanswers.com/treatmentinformation/treatmenttypes/stereotacticradiation.aspx Stereotactic Radiation Therapy Reference: http://www.radiologyinfo.org/en/info.cfm?pg=stereotactic

 179. Patient presents with varicose vein with sapheno-femoral incompetence and normal perforator management :

a. endovascular striping

b. Sclero-theraphy

c. Sapheno-femoral flush ligation

d. saphenofemoral flush ligation with striping

Answer: (d) saphenofemoral flush ligation with striping Reference: Bailey& Love, Short practice of Surgery, 25th Edition ,page No: 930, Sabiston textbook of surgery 18th Edition Chapter Primary Venus Insufficiency /below figure 68.6

STORY OF CALICHEAMICIN

STORY OF Calicheamicin

was discovered in 1981 (or 1987) by a scientist from Lederle Labs (now Wyeth) while on vacation in Kerrville, Texas (Other sources site Waco, Texas). The scientist collected a soil sample, which consisted of caliche clay, and sent it back to the lab for testing. Scientists grew a culture of the soil sample and found tiny bacteria within the sample produced a compound called "calicheamicin". Calicheamicin was found to be an incredibly potent cytotoxic agent and worked by destroying the DNA of cancer cells. Calicheamicin was so potent that it also destroyed the DNA of normal cells (1,000 to 10,000 times more cytotoxic to normal cells than drugs already on the market)..

 Dr. George Ellestad, Dr. Janis Upeslacis and Dr. Philip Hamann (Wyeth) began studying calicheamicin in order to better understand its mechanism. Together, they devised a plan to link calicheamicin to an antibody that specifically targeted cancer cells. In this way, they were able to keep calicheamicin from destroying normal cells because the antibody linker served as a "by pass" taking calicheamicin directly to the cancer cell.

 The FDA approved this new antibody-linked calicheamicin gemtuzumab ozogamicin. (go)) on May 17, 2000, almost 20 years after its discovery.

IT  is the very first drug in its class (antibody-targeted chemotherapy agents) and is used in the treatment of acute myelogenous leukemia. Remission rates of greater than 30% have been reported (Clinical Trials).

However, its effectiveness in early relapsing  LESS THAN 6 months or refractory AML patients is limited, possibly due to calicheamicin being a potent MDR1 substrate

Toxicity, including myelosuppression, infusion toxicity, and venoocclusive disease, can be observed with gemtuzumab ozogamicin.

Pretreatment with glucocorticoids can diminish many of the associated infusion reactions. Studies are examining this treatment in combination with chemotherapy for both young and older patients with previously untreated AML.

This agent has been withdrawn from the U.S. market at the request of the U.S. Food and Drug Administration due to concerns about the product's safety and clinical benefit as shown in trials subsequent to those leading to its accelerated approval.

CLOFARABINE

clofarabine

On December 28, 2004, the U.S. Food and Drug Administration approval for clofarabine purine nucleoside antimetabolite given by intravenous infusion for treatment of pediatric patients 1 to 21 years old with relapsed or refractory acute lymphoblastic leukemia after at least two prior regimens.

The principal clofarabine toxicities were

·         nausea, vomiting,

·         hematologic toxicity, febrile neutropenia, infections

·         hepatobiliary toxicity,

·         , and renal toxicity.

·         Clofarabine can produce systemic inflammatory response syndrome/capillary leak syndrome (SIRS), manifested by the rapid development of

o   tachypnea, tachycardia, hypotension, shock, and multi-organ failure.

·         Cardiac toxicity was characterized as left ventricular systolic dysfunction; tachycardia may also occur.

JNC 8 Has Finally Arrived

JNC 8 Has Finally Arrived

KEY POINTS

This guideline addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during treatment, and choice of antihypertensive agents.

Recommendations are as follows:

For younger patients (age, <60 are="" based="" be="" bp="" but="" considered="" diastolic="" drug="" evidence.="" for="" goal="" hg.="" hg="" high-quality="" is="" mm="" on="" only="" or="" p="" should="" systolic="" the="" therapy="" thresholds="">
For older patients (age, ≥60), drug therapy should be considered for diastolic BP ≥90 mm Hg or systolic BP ≥150 mm Hg; the goal is <150 hg.="" mm="" p="">
For patients with diabetes and patients with chronic kidney disease, the threshold to initiate drug therapy is 140/90 mm Hg; the goal is <140 hg.="" mm="" p="">
In nonblack patients, acceptable initial drug-class choices are thiazide-type diuretics, calcium-channel blockers (CCBs), angiotensin-converting–enzyme (ACE) inhibitors, and angiotensin-receptor blocker (ARBs).

In black patients, acceptable initial drug-class choices are thiazide-type diuretics or CCBs.

Patients with chronic kidney disease generally should receive ACE inhibitors or ARBs.

When patients require escalation of therapy, either maximizing doses of individual drugs sequentially or combining several drugs at submaximal doses is acceptable.

WHAT'S CHANGED JNC 7, the predecessor of this guideline, was a comprehensive document that covered not only hypertension treatment, but also definitions of hypertension, issues in BP measurement, public health perspectives, lifestyle modification, and “special situations” in hypertension management. In contrast, JNC 8 focuses narrowly on drug treatment. Moreover, recommendations in JNC 7 were informed liberally by extrapolation from observational data and by expert opinion, as well as by data from randomized trials. In contrast, recommendations in JNC 8 mostly reflect randomized trial–level evidence, with explicit acknowledgement when a recommendation reflects only expert opinion. JNC 8 is very transparent about its guideline-writing process, which aspired to the Institute of Medicine's report on creation of trustworthy guidelines. Two specific differences regarding treatment are as follows:JNC 7 recommended a treatment threshold of 140/90 mm Hg regardless of age, whereas JNC 8 raises the systolic threshold at age 60. In addition, JNC 7 recommended a lower treatment threshold (130/80 mm Hg) for patients with diabetes or chronic kidney disease, but JNC 8 does not.In JNC 7, thiazide-type diuretics were recommended as initial drug therapy (unless compelling reasons dictated another drug class), with CCBs, ACE inhibitors, ARBs, and β-blockers as alternates. In JNC 8, the initial drug choice is broadened to four classes for nonblack patients and two classes for black patients. β-blockers are no longer recommended for initial therapy because they might afford less protection against stroke.
 See more at: http://www.jwatch.org/na33228/2013/12/24/jnc-8-has-finally-arrived?query=etoc_jwcard#sthash.wkKfNXuc.dpuf

Gynecology MCQ,

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.

All are physiological changes during pregnancy except
a) distended neck veins
b) systemic hypotension
c) pedal edema
d) dyspnoea
ANS B

Wolff-Parkinson-White Syndrome

Pre-excitation Syndromes

Wolff-Parkinson-White Syndrome

see video good one..!!

ACLS - Ventricular Tachycardia and PEA

Ventricular tachycardia in all three flavors

ECG Clues Supporting the Diagnosis of Ventricular Tachycardia

ECG Clues Supporting the Diagnosis of Ventricular Tachycardia

1.    AV dissociation (atrial capture, fusion beats) 2.    QRS duration > 140 ms for RBBB type V1 morphology; V1 > 160 ms for LBBB type V1 morphology 3.    Frontal plane axis –90° to 180° 4.    Delayed activation during initial phase of the QRS complex 5.    LBBB pattern—R wave in V1, V2 >40 ms 6.    RBBB pattern—onset of R wave to nadir of S > 100 ms 7.    Bizarre QRS pattern that does not mimic typical RBBB or LBBB QRS complex 8.    Concordance of QRS complex in all precordial leads 9.    RS or dominant S in V6 for RBBB VT 10.Q wave in V6 with LBBB QRS pattern 11.Monophasic R or biphasic qR or R/S in V1 with RBBB pattern

Dr.Naren's Blizzard: Ventricular tachycardia

Short QT Syndrome

Short QT Syndrome

·       A gain in function of repolarization currents can result in a shortening of atrial and ventricular refractoriness and marked QT shortening on the surface ECG (Table 233-8). The T wave tends to be tall and peaked.

·       A QT interval <320 ms="" span="">is required to establish the diagnosis of this uncommon syndrome.

·       Mutations in the HERG, KvLQT1, and KCNJ2 genes have been identified.

·       Patients with the syndrome are predisposed to both

o   AF and VF.

·       ICD implantation is recommended.

o   Double counting of QRS and T waves may lead to inappropriate ICD shocks.

·       Drug therapy with quinidine

o   lengthen the QT interval and reduce the amplitude of the T wave.

Brugada Syndrome

Brugada Syndrome

·       The major clinical features of Brugada syndrome include

o   manifest, transient, or concealed ST segment elevation

o   in V1 to V3

o   that typically can be provoked with the

§  sodium channel-blocking drugs

·       ajmaline,

·       flecainide, and

·       procainamide and a

o   risk of polymorphic ventricular arrhythmias.

o   It appears that a diminished inward sodium current in the region of the RV outflow tract epicardium is responsible for Brugada syndrome (Table 233-8).

o   A loss of the action potential dome in the RV epicardium due to unopposed ITo potassium outward current results in dramatic shortening of the action potential.

o   The large potential difference between the normal endocardium and rapidly depolarized RV outflow epicardium gives rise to ST-segment elevation in V1–V3 in sinus rhythm and predisposes to local ventricular reentry (Fig. 233-14).

o   The majority of genetic abnormalities responsible for the syndrome have not been described; however, in ~20% of patients, mutations of SCN5A genes have been identified.

o   Although identified in both genders and all races with an autosomal dominant inheritance pattern, the arrhythmia syndrome is most common in young male patients (~75%) and is thought to be responsible for the sudden and unexpected nocturnal death syndrome (SUDS) described in Southeast Asian men.

o   The ventricular arrhythmia characteristically occurs with rest or during sleep. Fever and other sodium channel-blocking drugs have also precipitated ventricular arrhythmias.

·       The presence of spontaneous coved-type ST elevation in the right precordial leads and a history of syncope or aborted sudden cardiac death are predictors of an adverse outcome. Because of the overlap in SCN5A mutations, the association of Brugada syndrome with phenotypic LQT3 and conduction disturbances has been noted.

·       Treatment: Brugada Syndrome

·       A drug challenge with procainamide may be important to establish the diagnosis and the probable cause of unexplained syncope when the surface ECG is equivocal (saddleback ST elevation pattern).

·       Ajmaline and intravenous flecainide, which are not available in the United States, may have higher sensitivities for identifying the syndrome.

·       Successful acute management of recurrent VT has been reported with isoproterenol or quinidine administration, although experience has been limited.

·       Patients who do not benefit from beta blockers and chronic suppression with quinidine, which may lengthen epicardial action potential duration by blocking ITO current, may be considered for ICD implantation. ICD treatment to manage recurrences and prevent sudden death is recommended for all patients who have had documented arrhythmia episodes and patients with syncope and positive spontaneous or provoked coved-type ECG ST-segment changes in V1–V3.

·       Family members should undergo ECG screening for the presence of the abnormality.

·       The role of programmed cardiac stimulation and the use of ICD therapy in asymptomatic patients with the Brugada-type ECG pattern remain somewhat controversial, as is provocative drug infusion and programmed stimulation in patients with borderline abnormalities and no arrhythmia symptoms. Longer-term follow-up in a larger group of these relatively low-risk patients may be required before definitive recommendations can be provided. Counseling on controversies that exist, the potential risk of fever, and inadvertent administration of tricyclic antidepressants should be considered. Genetic testing may be helpful in confirming the presence of the genetic abnormality in family members of patients who manifest the arrhythmia syndrome.

BIDIRECTIONAL FASCICULAR TACHYCARDIA

The signature VT associated with  digoxin toxicity is bidirectional VT

BIDIRECTIONAL FASCICULAR TACHYCARDIA.

1.       Digoxin toxicity can produce increased ventricular ectopy and, when coupled with bradyarrhythmias caused by digoxin toxicity, may predispose to

a.       sustained polymorphic ventricular arrhythmias

b.      VF

c.       Birectional VT

2.       This unique VT is due to triggered activity associated with calcium overload resulting from the inhibition of Na+,K+-ATPase by digoxin.

3.       See fig--Bidirectional VT originates from the left anterior and posterior fascicles, creating

a.       relatively narrow QRS right bundle branch (RBB) configuration

b.       with  beat-to-beat alternating right and left frontal plane QRS axis.

   

4.       This VT seldom is observed in the absence of digoxin toxicity.

5.       Treatment for bidirectional VT or other hemodynamically significant arrhythmias due to digoxin excess

a.       correction of electrolyte disorders

b.       IV infusion of digoxin-specific Fab fragments.

                                                               i.      antibody fragments will, over the course of 1 hour, bind digoxin and eliminate toxic effects.

                                                             ii.      In the setting of normal renal function, the bound complex is secreted.

Gynae & Obs MCQS

Post menopausal estrogen therapy causes increase in which of the following
a) Cholesterol
b) VLDL
c) LDL
d) Triglycerides


Ans: d

On performing per vaginal examination the fingers could feel the anterior fontanelles and the superior orbital ridges. The presentation is
a) Vertex
b) Brow
c) Deflexed head
d) Flexed head
Ans: b

On examination of cervix after staining with acetic acid would help to identify all the following except-
a) Squamous metaplasia
b) Cervical carcinoma in situ
c) Cervical dysplasia
d) Cervical polyp
Ans: d

Pap smear would be useful in all of the following conditions except
a) Gonococcal infection
b) Human papilloma virus
c) Trychomoniasis
d) Inflammatory changes
Ans: a

In the management of post partum hemorrhage, all of the following can be used except
a) Ergometrine
b) Carboprost
c) Misoprostol
d) Mifeprestone
Ans: d

testis

 Which of the following is true regarding testis?
 a.Ectodermal origin
 b.Gubernaculum attached to the caudal end
 c.Surrounded by peritoneal tunica albuginea
 d.Reach the scrotum by 28th week

 answer: b. Gubernaculum attached to the caudal end.

ASA grading

Hyertensive man on medication with normal activity is graded under

 a. ASA I

 b. ASA II

 c. ASA III

 d. ASA IV

 answer: b.ASA II.

American Society of Anaesthesiologists (ASA)

The ASA score is a subjective assessment of a patient’s overall health that is based on five classes (I to V).

        I.            Patient is a completely healthy fit patient.

      II.            Patient has mild systemic disease.

    III.            Patient has severe systemic disease that is not incapacitating.

    IV.            Patient has incapacitating disease that is a constant threat to life.

      V.            A moribund patient who is not expected to live 24 hour with or without surgery.

E. Emergency surgery, E is placed after the Roman numeral.

Since inception it has been revised on several occasions and an ‘E’ suffix was included denoting an emergency case

IPC SECTIONS

Indian Penal Code 
Sec 44 Injury 
Sec 84 Act of a person of unsound mind/McNaughtens Rule 
Sec 85 Act of a person who is intoxicated against will 
Sec 191 & sec 193 definition and Punishment of perjury(Punishment up-to 7yrs ) 
Sec 197 Issuing or signing false certificate 
Offense Affecting Human Body 
Sec 299 to Sec 377 
• Sec 299 Culpable Homicide 
• Sec 300 Murder 
• Sec 302 Punishment of murder/infanticide* 
• Sec 304 Culpable Homicide not amounting to murder 
• Sec 304 A Causing death by negligence* ( punishment up-to 2yrs/fine ) 
• Sec 304 B Dowry Death 
Sections Related to Criminal Abortion 
• Sec 312 to Sec 316 
Abandonment of Child under 12 years 
• Sec 317 
Concealment of birth 
• Sec 318 
Hurt 
Sec 319 
Grievous Hurt 
IMP IPC SECTIONS 
• Sec 320 
Assault 
• Sec 351 
Assault to Outrage the Modesty of Women 
• Sec 354 
Rape 
Definition Sec 375 
Punishment Sec 376 
Section 228A. Disclosure of identity of the victim of certain offences etc like 
Sec 376 Criminal Procedure Code 
Sec 174 Police Inquest 
Sec 176 Magistrate’s Inquest 
Indian Evidence Act 
Sec 32 Dying Declaration