rapid review aipgmee, 2011

ANATOMY 1

Chapter 1Anatomy

1. In L5 root involvement, which among the following is not affected?

A.Thigh adduction B. Knee flexion C. Knee extension D. Toe extension

Ref: B.D Chaurasia 4th. Vol II. 59, 142 Tab 12.1, 148 Tab 12.2

Exp: Muscles Nerve supplyKnee extension: Quadriceps femoris (main) Femoral N (L

2,3,4)

Tensor fascia lata (accessory) Superior gluteal N (L4,5

S1)

Knee flexion: SemitendinosusSemimembranosus Tibial part of Sciatic N (L

5

S1,2

)Biceps femoris

Toe extension: Ext. digitorum longus Deep peroneal N (L4,5

S1)

Thigh Adduction: Adductor longus

Obturator N (L2,3,4

)Adductor brevisAdductor magnusPectineus (accessory)Gracilis ( ,, )

�Cleft b/w 1st & 2nd toes is supplied by: Deep peroneal nerve (L5) (PGI 1998)�Trendelenberg test is positive in damage of: Superior gluteal nerve (paralysisof gluteus medius & minimus)� Nerve damaged during venous cut down to access great saphenous vein:

Saphenous nerve (AI2008)� Largest cutaneous branch of femoral N: Saphenous nerve�Short saphenous vein is accompanied by: Sural nerve (a pure sensory branchof Tibial nerve)

1) A. Thigh Adduction

}}

Rapid Review AIPGMEE 20112

2. Which of the following passes through foramen magnum? (AI 2010)A. Internal Carotid Artery B. Sympathetic chain C. Hypoglossal Nerve D. Vertebral Artery

Ref: B.D.Chaurasia, 4th, Vol 3. 18Exp:

STRUCTURES PASSING THROUGH FORAMEN MAGNUM

2) D. Vertebral artery

Apical ligament of densVertical band of cruciate ligament Through Anterior partMembrana tectoria

Vertebral arteryAnt. Spinal arteryPost. Spinal artery Through Subarachnoid spaceSpinal accessory nerveSympathetic plexus around vertebral arteries

Lowest part of Medulla oblongata Through posterior partMeninges

}

}}

#Ant. spinal artery is a branch of: Vertebral artery. (PGI1993)#Vertebral artery is the First & Largest branch of first part of Subclavianartery.

Fig. Divisions of Vertebral Artery

ANATOMY 3

VERTEBRAL ARTERYDivisionsV1 : From origin to transverse process of C6 vertebra

Passes through vertebral triangleV2 : Runs through foramina transversaria of upper six cervical

vertebraeV3 : Lies in the sub-occipital triangleV4 : From post. atlanto occipital membrane to the lower border of

ponsPasses through foramen magnumPierces duramater, arachnoid & enters subarachnoid space*

(*AIIMS Nov 2005)Branches- Cervical branches

· Spinal branches· Muscular branches

- Cranial branches· PICA· Medullary artery· Ant. spinal artery· Rarely Post. spinal artery (usually it is a branch of PICA)


18. Basal metabolic rate is closely associated with:(AI 2009, 2010)

A. Lean body massB. Body surface area C. Body mass index D. Body weight

Ref: Ganong. 22nd. 282

Exp:BMR depends both on lean body mass and body surface area. But it is moreclosely related to lean body mass.� Lean body mass gives an estimate of metabolically active components i.e.,muscles & internal organsKatch-McArdle formula (BMR based on lean body weight)

BMR (men and women) = 370 + (21.6 X lean mass in kg)

FACTORS AFFECTING BMR

· Genetics. Some people are born with faster metabolisms; some withslower metabolism.

· Gender. Males > Females. Men have a greater muscle mass and a lowerbody fat percentage.

· Age. BMR reduces with age.· Weight. The heavier you are, the higher your BMR· Body Surface Area. This is a reflection of your height and weight. The

greater your Body Surface Area factor, the higher your BMR.Eg. Tall, thin people have higher BMRs.

Chapter 2 Physiology

18) A. Lean body mass

PHYSIOLOGY 31

26) D. Anterior nucleus of Thalamus

Fornix of Hippocampus (Limbicsystem)

Mammillary body(Hypothalamus)

Anterior thalamic nucleus

Cingulate gyrus(Limbic system)

DC: Diffusion capacity | N:Normal | * FEV1/FVC is the same as FEV

1 %

�Diffusion capacity is normal in Emphysema

�VC ¯̄̄̄̄ in both restrictive & obstructive lung diseasesQ. A young woman with exertional dyspnoea & PFT showing Normal FVC,Normal FEV

1/FVC & reduced DL

CO (Diffusion Lung capacity measured using

carbon monoxide) O2 saturation falls during exercise. Diagnosis is?

(AIIMS Nov 08|AI 10)Ans: Primary pulmonary HTN

26. The nucleus involved in Papez circuit is:(AI 2007)

A. PulvinarB. InfralaminarC. VPL nucleusD. Anterior nucleus of Thalamus

Ref: Guyton 11th . 732

Exp:

Papez circuit is a complex circuit involved in expression of emotions. It connectsthe limbic system with Hypothalamus & Thalamus.


Chapter 3 Biochemistry

27. Vitamin K is involved in the post-translational modification of:(AIIMS Nov 08, May 01)

A. Glutamate B. Aspartate C. LysineD. Proline

Ref: Harrison 17th. 743

Exp:

Gamma carboxylation of glutamic acid residues is the post-translationalmodification involved in Vit.K dependent clotting factors. Reduced Vit.K is theco-factor involved in this reaction and is converted to Vit.K epoxide.VIT. K DEPENDENT FACTORS· Clotting factors II, VII, IX, X

· Protein C, Protein S

· Osteocalcin, Bone Matrix GIa protein�Vit. C is required for post-translational modification of proline & lysine.(AIIMS Feb 97)�Vitamin excreted in urine is: Vit. CVIT. C: FUNCTIONS

· Collagen formation· Capillary integrity· Absorptionof iron· Part of ETC (Electron transport chain)· Thyroxine metabolism· Prevents atheromatous plaque formation

27) A. Glutamate

BIOCHEMISTRY 33

�Vit.A intoxication casues injury to: Lysososmes (AIIMS May07)�Vit. E toxicity affects: Lymphocytes�Bitoin is required for the activity of: Carboxylases (AIIMS May03)

�Warfarin acts by competitively inhibiting Vit.K epoxide reductase, thusdecreasing the availability of reduced Vit.K.�Ximelagartan: New oral anticoagulant, is a direct thrombin inhibitor.� Parenteral direct thrombin inhibitors: Lepirudin, Argatroban & Bivalirudin.�Fondaparinux, a synthetic pentasaccharide is a congener of LMW Heparinand acts by binding to antithrombin III and inhibiting Factor Xa.

28. NARP syndrome is seen in: (AIIMS Nov 09)A. Mitochondrial function disorderB. Glycogen storage disorder C. Lysosomal storage disorder D. Lipid storage disorder

Ref: Harrison’s 17th. 2568

Exp:

Neuropathy, Ataxia and Retinitis Pigmentosa (NARP) syndrome is amitochondrial function disorder arising from mutation of ATP-ase 6(Complex-5)MITOCHONDRIAL DISORDERS (maternal inheritance/heteroplasmy)

· MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis & Stroke)

· Kearns-Sayre syndrome· NARP syndrome· Myoclonic Epilepsy with Ragged Red Fibres (MERRF)· C/c Progressive External Ophthalmoplegia (CPEO)

�Retinitis pigmentosa (RP ) is associated with:· Bassen-Kornzweig syndrome (Abetalipoproteinemia)· Refsum’s disease· Usher’s syndrome· Kearns-Sayre syndrome

28) A. Mitochondrial function disorder


Chapter 4 Pharmacology37. Drug of choice for central Diabetes insipidus is:A. DesmopressinB. LeuprolideC. Thiazide diureticsD. Lithium

Ref: Harrison. 17th. 2220

Exp: The signs and symptoms of uncomplicated pituitary DI can be eliminatedcompletely by treatment with desmopressin (DDAVP: 1-desamino-8-D-argininevasopressin).Desmopressin

· Longer acting, V2 selective, synthetic analogue of AVP -Acts selectively at V

2 receptors to increase urine concentration and

decrease urine flow. -More resistant to degradation than AVP and has 3-4 fold longerduration of action.

· Uses: 1. DOC for nocturnal enuresis. 2. Also used in Von-Willebrand’s disease

· Routes of administration: I.V, SC injection, Nasal inhalation or Oral.� Drugs used in Nephrogenic DI

1. Thiazide diuretics2. Indomethacin3. Amiloride in conjunction with low Na diet

�DIDMOAD syndrome (Wolfram’s syndrome): Diabetes insipidus, Diabetesmellitus, Optic atrophy & Deafness (neural)SIADH: Characterised by excessive release of ADH (vasopressin) whichenhances the reabsorption of water, resulting in concentrated urine &hyponatremia.

37) A. Desmopressin

PHARMACOLOGY 43

�Treatment of SIADH:1. Conivaptan (DOC, V2 + V1 antagonist)2. Demeclocycline

�Drugs causing SIADH: 1.Vasopressin2. Chlorpropamide3. Vincristine4. Carbamazepine5. Nicotine6. Phenothiazines7. Cyclophosphamide8. TCA9. MOA inhibitors10. SSRI

Vasopressin receptors Action

V1 a Vasoconstriction

V2 Water absorption in collecting duct via Aquaporin2VasodilatationRelease of Von-Willebrand factor& Factor VIII from endothelium

V1b (V3) Release of ACTH from pituitary

�Lypressin & Terlipressin (V1+V2 analogues): Both are used for the controlof esophageal variceal bleeding.

38. All are true regarding Selective estrogen-receptor downregulator(SERD), Fulvestrant except:A. Used for breast cancer B. Is a selective estrogen antagonist C. Is slower acting, safer & less effective than SERM D. Given as once a month i.m. dose

Ref: Goodman & Gilman 34.FulvestrantFulvestrant is the first FDA approved agent in the new class of estrogen-receptordownregulators (SERD), which were hypothesized to have an improved safetyprofile, faster onset and longer duration of action than the SERMs due to theirpure ER antagonist activity . It was approved in 2002 for

38. C. Is slower acting, safer & less effective than SERM

67PATHOLOGY

64. Which of the following is not associated with atherosclerotic plaqueformation?

A. Plasma ApoEB. Alpha-2-macroglobulin C. Oxidised LDL D. Increased homocysteine Ref: 1. Harrison’s 17th. 2419, Tab-350-4

2. Robbin’s 7th. 521

Exp:

Alpha-2-macroglobulin has no relation with atherosclerosis.� Risk Factors for Atherosclerosis include:· Advanced age· Male sex· Genetic factors (polygenic)· Hyperlipidemia (- LDL, Lp(a)), ApoE mutation· Hypertension· Cigarette smoking· Diabetes mellitus· S. Homocysteine > 100umol/L· Prothrombic factors (- Plasminogen Activated Inhibitor-1)· Inflammatory factors- ----- CRP (most important factor in risk production)· ? Chlamydial infection (not fully proven)

Chapter 5 Pathology

64) B. Alpha-2-macroglobulin

68 Rapid Review AIPGMEE 2011

METABOLIC SYNDROME (Syndrome X)Diagnosis requires 3 or more of the following

· Central obesity: Waist circumference > 102 cm (M), > 88 cm (F)· Hypertriglyceridemia: Triglycerides >150 mg/dL· Low HDL: <40 mg/dL (M) & <50 mg/dL (F)· Hypertension: B.P >130 mm systolic or >85 mm diastolic· Fasting plasma glucose > 100mg/dL

65. Which is not an autoimmune disease? A. SLE B. Grave’s disease C. Myasthenia gravis D. Sickle cell diseaseExp:

As we know, Sickle cell disease is a hemoglobinopathy and not anautoimmune disease.�Gamma Gandy bodies are seen in: Sickle cell anemia (AIIMS, Nov93)� Commonest renal manifestation in Sickle cell trait: IsosthenuriaSickling: Mutation in Sickle cell anemia leads to: GAG � GUG (Adenine isreplaced by Uracil).In effect, polar glutamic acid is replaced by non-polar valine. The amino acidsubstitution creates a site on the surface of the Hemoglobin molecule, sometimesreferred to as “sticky patch”. Only deoxyhemoglobin S has a complementarysite to this sticky patch. Therefore deoxyhemoglobin molecules in the RBCbind to each other and polymerize into long fibers that distort it’s shape.Note: Sticky patch is present on both oxygenated & deoxygenated HbS. But, inoxygenated HbS molecule, the complementary site is masked. This is the reasonbehind deoxygenation favouring sickling. (AI, 2009)

�Role of HbA in polymerisation: HbA does not contain any sticky patch. But itdoes have a binding site for sticky patch. Thus it can bind to HbS but cannotextend the polymer. That is how HbA interferes with polymerisation.

(AIIMS Nov, 2004)

65) D. Sickle cell disease


Chapter 6 Microbiology

78. Tetracycline is used in the prophylaxis of which of the followingdiseases? (AIIMS 2005)

A. CholeraB. BrucellosisC. LeptospirosisD. Meningitis


Exp:

Tetracycline is used in chemoprophylaxis of Cholera.

PROPHYLACTIC USE OF ANTIBIOTICS· Leptospirosis: Doxycycline (Pencillin G is used for Rx)· Meningococcal meningitis: Rifampicin· Infleunza: Oseltamivir· Rickettsial infections: Tetracyclines· Rheumatic fever: Pencillin· Gonorrhea/Syphilis: Pencillin· Plague: Tetracycline/Doxycycline (Streptomycin is used for Rx)· Cholera: Doxycycline/Tetracycline· Diphtheria: Erythromycin (AI 2008)

�Drug used for the Rx of cholera in adults: Doxycycline (AI 2005)�DOC for Rx of cholera in pregnancy: Furazolidone (AIIMS 2005)

78) A. Cholera


81. A farmer developed swellings in the inguinal region which later ulceratedalong with development of constitutional symptoms. What stain can beused to detect the bipolar stained organisms? (AI 2006)A. Albert’s stain B. Wayson stain C. Ziehl–Neelsen stainD. Nigrosin stain


Exp:

This is a case of Bubonic plague and the inguinal smear should be examinedimmediately with Wayson or Giemsa stain.� Yersinia pestis· Gram negative, non-motile, oxidase negative coccobacillus

· Bipolar staining (safety pin appearance)· Stalactite growth in Ghee broth· DOC: Streptomycin. The drug used for chemoprophylaxis isTetracycline�Another gram-negative bacillus showing bipolar staining, but motile& oxidase positive is Burkholderia pseudomallei causing Meliodosis.

(AIIMS Nov 2003).82. Which among the following is the most common fungal infection seenin immunocompetent patients? A. AspergillusB. Candida C. Cryptococcus D. Penicillium marneffei

Ref: 1. Greenwood 16th. 5752. Textbook of Diagnostic Microbiolgy 3rd. 7453. Robbins 7th. 397

Exp:

Candida is the most common fungal infection in immunocompetent individuals,most commonly Candida albicans.-Prevalence of Aspergillus is second only to Candida albicans.

81) B. Wayson stain 82) B. Candida

FORENSIC MEDICINE 101

Chapter 7 Forensic

Medicine

104. An Infant is brought to the casualty with reports of violent shakingby parents. Most characteristic injury is:A. Long bone fracture B. Ruptured spleen C. Subdural hematoma D. Skull bone fracture

Ref: Reddy, 25th. 383

Exp:

This is a case of Battered Baby syndrome (non-accidental injury ofchildhood).

Battered Baby syndrome is characterised by bruises, abrasions & lacerationsof different ages due to direct manual violence. Battered babies are frequentlyfound to have subdural hematoma & intraocular bleeding due to violentshaking, so also called ‘infantile whiplash syndrome’. In such cases there is nofracture of skull or no external injuries on the head or body other than bruisesproduced in areas where the child is held by the hands.

104) C. Subdural hematoma


105. Gun powder on clothing can be visualized by:A. Magnifying lens B. UV rays C. Infrared rays D. Xray

Ref: Parikh 6th. 2.18

Exp:

Soot deposits (blackening) & gun powder on dark coloured fabric & skin canbe better visualised by IR photography.�All tattoos & faint letter marks can be visualised by: IR photography

(AI 1991,2003|AIIMS 1992)Tests for gun powder detection:

· IR photography· Dermal nitrate/ Paraffin test (AIIMS Nov 2005)· Neutron activation analysis· Atomic absorption spectrophotometry· Scanning electron microscopy with Xray analyser

�Black gun powder (smoke producing) contains: Pot. Nitrate, Sulphur,Charcoal (PGI Dec 2006|AIIMS 1997)�Smokeless gun powder contains: Nitrocellulose & nitroglycrine�The terms FG, FFG, FFFG are used to describe: Black gun powder (dependingon size of grains) (PGI Jun 2007, Dec 2008)�Dried semen stain on clothes is identified by: UV light (AIIMS Nov 2009)106. Signature fracture refers to: (AIIMS May 2006)A. Depressed skull fractureB. Suture displacement fracture C. Contrecoup injury D. Fracture at foramen magnum Ref: Reddy, 25th. 209

Exp:

Depressed fracture is also known as Signature fracture (fracture-ala signature),as their pattern often resembles the weapon or agent which caused it.

105) C. Infrared rays 106) A. Depressed fracture


Chapter 8 Community

Medicine

113. Which is not true regarding diet modification recommended in highcardiovascular risk groups?

A. Cholesterol less than 100 mg/1000kcal/day B. Avoid alcohol C. Fat intake < 10% of total caloriesD. Salt limitation to less than 5 gmRef: Park 20th. 320

Exp:

The WHO committee considers the following dietary changes necessary forprevention of CHD

· Reduction of fat intake to 20-30% of total energy intake

· Saturated fat < 10% of total energy intake

· Cholesterol <100mg/1000kcal/day

· Increase in complex carbohydrate consumption

· Avoid alcohol

· Salt intake <5g/day

114. Orthotoluidine test is used for detecting: (AIIMS Nov 04,PGI June 06)

A. ChlorineB. Nitrites C. Nitrates D. AmmoniaRef: Park 20th. 626Exp:

-Orthotoluidine test determines both free and combined chlorine in watertogether.

113) C Fat intake <10% of total calories 114) A. Chlorine

COMMUNITY MEDICINE 109

(Free chlorine is detected within 10 seconds. Combined chlorine within 15-20min.)

-Orthotoluidine-Arsenite test determines free and combined chlorineseparately.

CHLORINE DEMANDThe difference between the amount of chlorine added to water and the amount

of residual chlorine remaining at the end of contact time of 1 hour.�Break-point: The point at which chlorine demand of water is met.�Chlorine demand of water can be estimated by: Horrock’s apparatus.

(AIIMS May 2006, 2007)Estimation of chlorine demand:1. Calculate volume (Litres) of water in well using formula 3.14x R2 x h x10002. Check which cup (1 to 6) of Horrock’s apparatus shows blue colour when

tested with the water sample to be purified (details in Park p.637)3. For example : If it is the 4th cup, 8g (i.e., 4x2) bleaching powder is required

for 455 Litres of water in that well. Then calculate the amount requiredfor the entire volume in well.

�Action of chlorine is due to: Hypochlorous acid (HClO).

�Methods of chlorination: 1. Chlorine gas 2. Chloramine 3. Perchloron (High Test Hypochlorite)-contains 60-70% of available chlorine.�Chlorine kills pathogenic bacteria, but has no effect on spores and certainviruses (Eg. polio, viral hepatits) except at high doses (Superchlorination).�Ozone and UV radiation are more effective than chlorine (have virucidal effectalso). But there will be no residual germicidal effect.�Bleaching powder (CaOCl

2) contains 33% available chlorine. Used for

household purification.

�Drinking water requires a residual chlorine level of 0.5 ppm for a contactperiod of 1 hour. (AIIMS May04)�In post disaster period: 0.7 ppm for contact period of 1 hour.�Swimming pool disinfection : 1 ppm for 1 hour.

E N T 129

Chapter 9 ENT

137. A 5 year old boy while having dinner suddenly becomes aphonic andis brought to the casualty with complaint of respiratory distress. Whatshould be the appropriate management? (AIIMS1999|AI2002)

A. Cricothyroidotomy B. Emergency tracheostomy C. Humidified oxygenD. Heimlich manoeuvre

Ref: Dhingra 3rd. 389

Exp:

This is a case of laryngeal foreign body. Emergency management, especiallywhen the patient is not in a hospital setup is Heimlich’s manoeuvre. Standbehind the patient and place your arms around his lower chest and givestrong abdominal thrusts. In pediatric patients pounding the back afterturning the patient head down may be tried. If all attempts fail,cricothyrotomy (laryngotomy) should be performed. It should be convertedto tracheostomy later.

138. Time of occurrence of secondary haemorrhage after tonsillectomy:(JIPMER 2003)

A. 24 hrs B. 6 daysC. 12 days D. 12 hrs

Ref: Dhingra 3rd. 492

137) Ans: D. Heimlich manoeuvre 138) B. 6 Days


Exp:

Secondary hemorrhage after tonsillectomy is seen between 5th to 10th

post-operative day. Usually occurs after 7 days. Infection in thetonsillar fossa is the cause for secondary hemorrhage.

�Cause of reactionary haemorrhage is slipping of ligatures. It occurs within 24hours.

139. Gold standard test for diagnosis of laryngopharyngeal reflux is: A. 24 hr double probe pH monitoringB. Flexible endoscopy C. Barium swallow D. Laryngoscopy

Ref: Ballinger’s textbook of ENT 17th. 886

Exp:

The gold standard for diagnosing and quantifying acid reflux is the 24-hourdouble probe pH monitoring.

Procedure: The study is performed by placing a thin catheter containing one ormore solid-state electrodes in the esophagus. The electrodes are spaced 5to 10 cm apart and are capable of sensing fluctuations in the pH between 2and 7. The electrodes are connected to a data recorder that the patientwears for the period of observation. There is a digital clock displayed onthe recorder. When the patient has an event (e.g., heartburn, chest pain,eructation), he or she is to record the event in a diary, noting the time onthe recorder.

�Laryngeal pseudosulcus is seen secondary to: Laryngopharyngeal reflux(AI 2009)

�A singer with singer’s node with history of reflux, the best treatment is: Voicetherapy & PPI (AI 2008)

Complications of Laryngopharyngeal reflux (Reflux laryngitis)· Subglottic stenosis (PGI 2004)· Ca larynx· Cord fixation· Contact ulcer· Vocal nodule

139) A. 24hr double probe pH monitoring

OPHTHALMOLOGY 135

Chapter 10 Ophthalmology145. Which of the following is the most probable diagnosis in a young patient

with loss of central vision and a normal ERG with no family history? A. Best’s disease B. Stargardt’s diseaseC. Retinitis pigmentosa D. Central macular holeRef: Kanski Ophthalmology 5th. 498, 507Exp: Patient with loss of central vision & normal ERG, narrows down our

diagnoses to Best’s disease & Stargardt’s disease. However, Best’s diseasecan be excluded as it usually appears during childhood & family historywill be invariably present as the condition is autosomal dominant.

Stargradt’s disease usually manifests in young individuals (late second decade& third decade) & it does not usually have a family history as the conditionis AR.

Stargardt’s DiseaseClinical features· AR disorder· Most common form of inherited juvenile macular dystrophy· Characterised by B/L discrete yellowish flecks of lipofuschin deposition in

the macula· Macular damages start to occur b/w 6 -20 yrs though visual impairment

becomes apparent in the 3rd decade· Patients typically present after 20 yrs with gradual blurring of central vision

& black or hazy spots in the centre of their vision· Vision suddenly deteriorates thereafter

InvestigationsFluorescein angiography: Investigation of choice (shows dark choroid)Electroretinogram (ERG), (Electrooculogram) (EOG): Usually normal or may

be subnormal

145) B. Stargardt’s disease


Rx: No effective treatment available

MACULAR DYSTROPHIESAR AD

· Stargradt’s disease (juvenile MD)· Fundus flavimaculatus· Bassen kornzweig disease· Rufsum’s disease· Usher’s syndrome· Laurence Moon Biedl syndrome

�Best diagnostic test for Best’s disease: EOGEOG is abnormal in Best’s disease. It is the only disease showing relatively

normal ERG with abnormal EOG (JIPMER 1999)

�Most of the Retinal dystrophies are AR inherited except: Best’s disease& Butterfly MD�Most of the Corneal dystrophies are AD inherited except: Macularcorneal dystrophy (AI1996)

Electroretinogram (ERG)Measures changes in the resting potential of eye, induced by stimulation of theeye with a light stimulus.

In a normal dark adapted eye, ERG shows 3 components:1. Negative ‘a’ wave- represents activity of rods & cones2. Positive ‘b’ wave- arises in inner retinal layers3. ‘c’ wave- related to metabolism of retinal pigment epithelium

· Juvenile Best’s disease*(vitelliform MD)

· Butterfly MD

(*AIIMS Nov 06, May 07|AI 07)

(JIPMER 2004)

MEDICINE 145

Chapter 11 Medicine

155. A girl presented with recurrent occipital headache associated withataxia and vertigo. There is history of her mother having similarcomplaints. Most probable diagnosis is: (AIIMS Nov 2009)

A. Vestibular neuronitis B. Basilar migraine C. TIAD. –Ref: Harrison’s 17th. 141

Exp: The above mentioned clinical scenario correlates with Basilar migraine.Ataxia is due to involvement of cerebellar nuclei and vertigo due tovestibular nuclei. Both are supplied by branches of basilar artery.

Basilar Migraine: It can be familial and classically the pain is occipital.Clinical features· Occipital headache· Visual symptoms· Dysarthria· Ataxia· Vertigo· Tinnitus

�Retinal migraine: Migraine with involvement of retinal circulation which causesunilateral photopsia/transient monocular blindness.

�Ophthalmoplegic migraine: Migraine with transient, partial 3rd nerve palsy.(AIIMS May, 2003)

�Hemiplegic migraine: AD trait characterized by episodes of hemiparesis alongwith migraine.

155) B. Basilar migraine


MIGRAINE

With aura: Classical migraine (*AIIMS Jun, 2000|AI 2001)· Recurrent U/L headache with nausea/vomiting & preceded by an aura

which is usually a disturbance of nervous functionEg. Photopsia, Scintillating scotoma, Paresthesia–lips, face &hands*, Transient weakness, Aphasia, Dysarthria etc.

Without aura: Common migraine· 5 times more common than classical migraine· No aura preceeding headache· Nausea/ vomiting +· Hemicranial throbbing headache usually affecting frontotemporal part· Sensitivity to light & noise is characterisitic

Drugs for Rx of migraine

· 5HT 1B/1D receptor agonist: Sumatriptan, Rizatriptan, Zolmitriptan· NSAIDs· Dopamine antagonists: Metoclopramide, Chlorpromazine

Drugs for Prophylaxis· Propranolol· TCAs· Anticonvulsants: Topiramate, Valproate, Gabapentin· Verapamil· Methysergide· Flunarazine

�Sumatriptan is not used for prophylaxis of migraine (AI 2010)

CLUSTER HEADACHE (AIIMS Nov 1999)

· Occurs predominantly in young men· U/L intense, non-throbbing, periorbital pain associated

with reddening of eye, lacrimation, rhinorrhea & nasal stuffiness· Headache occurs in clusters· Usually at night


Chapter 12 Surgery

195. A surgeon removed the part of liver to the left of the falciform ligament.Which segments have been removed? (AI 2008)

A. 1 & 4aB. 2 & 3C. 1 & 4bD. 5 & 6Ref: Bailey 24th. 1063: Fig 63.2, 18: Fig 2.24Exp:

Resection of segments II and III is a commonly performed sublobarresection and is often referred to as a left lateral segmentectomy andleft lateral sectionectomy or left lobectomy. Left lobe is that part ofliver to the left of the falciform ligament.

Couinad & Bismuth (French) classification

(Functional segmental liver anatomy)-Liver is divided into 8 functional segments based on distribution of He-

patic vein (mainly) & Portal vein.(AI 2004)

-Couinaud's segments are numbered in anti-clockwise direction when liveris visualized from posterior surface.

· Segment I is called Caudate lobe· Segment IV is called Quadrate lobe

195) B.2 & 3

SURGERY 197

Anatomical classification Surgical classificationFalciform ligamentdivides liver into:Left (II, III) & Right(I, IV,V, VI, VII, VIII) lobes

Cantlie's line*/Portal fissure dividesliver into functional Left (II, III, IV)& Right (V, VI,VII, VIII) lobes· Left lobe is supplied by Left he-

patic atrtery & Left portal vein;and drained by Left hepatic vein

· Right lobe is supplied by Righthepatic atrtery & Right portalvein; and drained by Right he-patic vein

· Caudate lobe enjoys dual bloodsupply

(*line passing through gall bladder fossa, middle hepatic vein & IVC)�The lobe enlarged in Budd-Chiari syndrome: Caudate lobe

196. Difference between follicular carcinoma and follicular adenoma is:

A. Vascular invasion

B. Mitosis

C. Nuclear pleomorphism

D. Hurthle cells

Ref: Robbins 7th. 1177

Exp:

Capsular & vascular invasion differentiates follicular carcinoma from folli-cular adenoma.

� Follicular carcinoma:

· 2nd most common Thyroid malignancy

· More common in iodine deficient areas

196) A Vascular invasion


Chapter 13 Obstetrics &

Gynaecology

217. Blood Chimerism is associated with:A. Monochorionic monoamniotic twins

B. Monochorionic dizygotic twins

C. Singleton pregnancyD. Vanishing twin

Ref: 1. Journal: Blood Chimerism in a Dizygotic Dichorionic Pregnancy

2. Blood chimerism in monochorionic twins conceived by induced

ovulation: Case report"

Exp:

Chimerism means a person shows 2 cell lines derived from 2 different zygotes.

Blood chimerism is the presence of cells from 2 zygote lineages in lympho-

hematopoietic system alone.

Cells from one fetus will reach the other via vascular connections between the

two. This usually happens in monochorionic twins and it will not result inchimerism as monochorionic twins are monozygotic as well. (Both fetuses

contain the same cell line. So even if cells are mixed, it will not be apparent).

So blood chimerism will occur only when 2 zygotes share a single placenta and

vascular connections develop.

Traditionally, monochorionicity in multiple pregnancies is associated with

monozygocity. Dizygotic monochorionic twins will not develop in natural

twin pregnancy, but may occur in 'in vitro fertilisation'. Only few cases

217) B. Monochorionic dizygotic twins

O & G 217

have been reported so far. In IVF 3 or 4 zygotes are grown together artificially

and all are introduced into uterus. In this scenario they may develop singlechorion/placenta.

Investigations: To distinguish whole-body chimerism from blood chimerism,molecular analysis of blood cells and non-hematopoietic tissue (e.g., buccal

cells, hair, and nails) by performing PCR and FISH is necessary.

Eg. We present a case of blood chimerism in a dizygotic monochorionic twinpregnancy.

The female twin was delivered at 34 weeks of gestation, and the male twin wasstillborn. Pathologic examination confirmed Monochorionic diamniotic

placenta. The karyotype of the female child was obtained using

peripheral blood sample, and it revealed a mixture of 46,XX and46,XY cells . FISH analysis performed on the buccal cells revealed

100% XX signals. Gross examination of the external genitalia and

abdominal ultrasonography revealed no definitive abnormal findingsin relation to sex differentiation. When XX/XY chimerism is present

in blood lymphocytes, careful examination of external genitalia and

reproductive organs and further studies are required to detectchimerism in non-hematopoetic tissues. So it is a case of blood

chimerism.

218. In expectant management of placenta praevia, all are done except:(AIIMS Nov 2010)

A. Cervical encirclage

B. Anti D administration

C. Corticosteroids

D. Blood transfusion

Ref: Dutta 6th. 251

Exp:

Expectant management of placenta praevia (Macafee & Johnson regimen)

is followed when:

218) A. Cervical encirclage


Chapter 14 Orthopaedics

247. A 65 yrs old lady presented with a swollen and painful knee. Onexamination, she was found to have grade III osteoarthritic changes. Whatis the best course of action?A. Conservative managementB. Arthroscopic washingC. Partial knee replacementD. Total knee replacementRef: 1. Campbell 11th. 916 2. Apley‘s 9th. 573

Exp:

The radiological grading system for OA is Kellgren-Lawrence scale given below.However, the treatment of OA is not dependent on radiological grading. It isonly based on symptoms & disability of the patient. Moreover, the radiologicalgrading may not correlate with symptomatology.Kellgren-Lawrence Grading Scale

Grade 1: doubtful narrowing of joint space and possible osteophytic lipping·Grade 2: definite osteophytes, definite narrowing of joint space·Grade 3: moderate multiple osteophytes, definite narrowing of joints space,some sclerosis and possible deformity of bone contour·Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis

and definite deformity of bone contourThe patient in the question is 65 yr old & is having swollen & painful knee.The best treatment here is Total knee replacement.�Treatment options for OA

247) D. Total knee replacement

ORTHOPAEDICS 243

A. Conservative

· Drugs-NSAIDs, Intraarterial steroids, Hyaluronic acid

· Weight reduction

· Exercise

· Orthoses

B. Surgical

· Arthroscopic wash out

· Osteotomy

· Arthroplasty

· Arthrodesis

248. Blount’s disease is: (PGI Jun 2000)A. Genu valgumB. Genu varumC. Genu recurvatumD. Menisceal injury

Ref: Bailey & Love 24th. 489

Exp:

BLOUNT’S DISEASE (infantile tibia vara)

-Pediatric (<3yrs) orthopaedic disorder affecting the knee joint.

-Rare growth disorder is characterized by disordered ossification of the medialaspect of the proximal tibial epiphysis and metaphysis

-Progressive deformity manifests as varus angulation and internal rotationof the tibia in the proximal metaphyseal region immediately below theknee.

X-ray: Shows beaking & fragmentation of medial tibial epiphysis.

Rx: Corrective osteotomy (should be done before 4yrs; critical age of

osteotomy) (JIPMER 1998)

248) B. Genu varum

PEDIATRICS 249

252. Earliest symptom of GERD which becomes pathological in aninfant is:A. Respiratory distressB. Upper GI bleedC. RegurgitationD. Intestinal obstructionRef: Nelson 18th. 1547

Exp:

-GERD in infants may manifest as obstructive apnoea or as stridor or lowerairway disease. It may also complicate primary airway disease such aslaryngomalacia or bronchopulmonary dysplasia. Otitis media, sinusitis,lymphoid hyperplasia, hoarseness, vocal cord nodules, and laryngeal edemahave all been associated with GERD.-Infantile reflux manifests more often with regurgitation (especiallypostprandially), signs of esophagitis (irritability, arching, choking, gagging,feeding aversion), and resulting failure to thrive, symptoms resolve spontaneouslyin the majority by 12–24 months. If a question appears based on ‘most commonmanifestaion’ the answer will be Postprandial regurgitation.But most common pathological presentation is with ‘Respiratory distress.’

253. A 7 month old child presents with complaints of recurrent bouts of

Chapter 15 Pediatrics

252) A. Respiratory distress


cough terminated by an audible whoop. What is the best way to confirmthe diagnosis?

A. Nasopharyngeal swab

B. Cough plate culture

C. Tracheal aspirate

D. –

Ref: 1. Harrison’s 17th. 935

2. Jawetz Microbiology

Exp:

The best specimen for diagnosis of Pertussis is collected by nasopharyngealaspiration, in which a fine flexible plastic catheter attached to a 10-ml syringe ispassed into the nasopharynx and withdrawn while gentle suction is applied.This should be inoculated without delay on to Bordet-Gengou agar*. Cultureof nasopharyngeal secretions remains the gold standard of diagnosis, althoughDNA detection by polymerase chain reaction (PCR) is replacing culture in manylaboratories because of increased sensitivity and quicker results. (*PGI 1994)

Note: As per Jawetz Microbiology,

“A saline nasal wash is the preferred specimen. Nasopharyngeal swabs orcough droplets expelled onto a “cough plate” held in front of the patient’s mouthduring a paroxysm are sometimes used but are not as good as the saline nasalwash.”

Thus, if saline nasal wash was among the options it would have been the answer.

�Usual incubation period of Pertussis: 7-14 days (AIIMS Nov 2005)

�In culture medium Bordetella produces:

a. Bisected pearls/mercury drops colonies.

b. Aluminium paint appearance (Confluent growth )

c. Thumb print appearance

253) A. Nasopharyngeal swab


269. Erythema nodosum is seen in all except: (AIIMS 1994)

A. Pregnancy B. Tuberculosis C. SLE D. Chronic pancreatitisRef: 1. Harrison17th. 126, 333 Tab 18-1

2. Fitzpatrick Dermatology 6th. 1940

Exp:

Causes of Erythema nodosum:· Streptococcal Infection (MC cause)

· Sarcoidosis· Drugs-Sulphonamides, Penicillin, OCP

· Hodgkin’s disease

· TB· Leprosy

· Brucellosis

· Ulcerative colitis & Crohn’s dsease· SLE

· Pregnancy

· Behcet’s disease· Fungal infections

· Histoplasmosis

Chapter 16 Dermatology

269) D. Chronic pancreatitis

DERMATOLOGY 267

Tuberculides are hypersensitive reactions to mycobacterium tuberculosisor its products in a patient with significant immunity

a. True Tuberculides: (AIIMS Nov 2006, May 2007|PGI Jun 2007)

1. Lichen scrofulosorum

2. Papulonecrotic tuberculide

b. Facultative tuberculides:

1.Erythema nodosum

2. Erythema induratum (Nodular tuberculid)

�Most common type of cutaneous TB: Lupus vulgaris (Apple jellynodules) (PGI Dec 2006)

�Lupus vulgaris: Cutaneous TB characterized by erythematous, annular,irregularly indurated plaque with central scarring.

(AIIMS Nov 2001, Nov 2003)

�Erythematous lesion with central crusting: Cutaneous Leishmaniasis

�Lesion with central clearing: Tinea corporis

�Cutaneous TB secondary to underlying TB lymphadenitis: Scrofuloderma(AI 1999)

270. Pseudoisomorphic phenomenon is seen in: (AI 1991|PGI 1999)

A. Psoriasis

B. Lichen planus

C. Vitiligo

D. Plane warts

Ref: Fizpatricks’ dermatology 6th.427

Exp:

-Pseudoisomorhic phenomenon: Due to autoinoculation & is seen in infections

like Plane warts, Molluscum contagiosum & Eczematous lesions

-Isomorphic/Koebner’s phenomenon: Appearance of lesion at the site of minortrauma.

It is seen in:

270) D. Plane warts


273. Spinal anesthesia is given at: (AI 1997)A. L1-L2 B. L2-L4

C. S1 D. Thoracic segment

Ref: Morgan’s Anaesthesiology 3rd. 253

Exp:

-Spinal anesthesia is usually performed at the level of the L3 or L4 vertebrae

in the adult patient, because the spinal needle is introduced below the level at

which the spinal cord ends (lower border of L1).-In children, as spinal cord extends upto upper border of L3, spinal

anesthesia is given at L4-L5 interspace.

274. Epileptogenic anesthetic agent of the following is:A. Desflurane B. Halothane

C. Sevoflurane

D. Ether Ref: Web. http://www.ncbi.nlm.nih.gov/pubmed/14581667

Sevoflurane consistently produces cortical epileptiform discharges and is dose

dependently epileptogenic at surgical levels of anesthesia.

�Inhalational anesthetic agents C/I in patients with h/o epilepsy: Enflurane &

Etomidate (AIIMS 2003)

Chapter 17 Anaesthesiology

273) B. L2-L4 274) C. Sevoflurane

ANAESTHESIOLOGY 271

�I.V anesthetic agent producing raised ICT: Ketamine

(AI 2000|AIIMS Nov 2007)�Inhalational anesthetic agent of choice for induction of anesthesia in

children: Sevoflurane (AIIMS May 2004)

275. Which of the following anesthetic drugs is contraindicated in a patientwith hypertension? A. Ketamine

B. Propofol C. Etomidate

D. Diazepam

Ref: Morgan’s Anaesthesiology 3rd. 170

Exp:

Ketamine increases all pressures (ICT/IOP/BP) & muscle tone due tosympathetic stimulation.KETAMINE· Causes dissociative anesthesia & emergence psychomimetic

hallucinations. (AIIMS Nov 2006)· Anesthetic of choice in Shock (SGPGI 2002)

· Anesthetic of choice in Status asthmaticus

· Dose: 2mg/kg i.v (AIIMS 1993)

�Succinyl choline increases all pressures like Ketamine�Cerebroprotective anesthetic agents:

(PGI Dec 2004|AIIMS Nov, 2007)

····· Thiopentone sodium

· Propofol

�Dose of Thiopentone sodium: 5mg/kg (3-5mg/kg Think: ‘Trio-Pentone’*)(JIPMER 1996)

(*Courtesy: www.lifehugger.com)

275) A. Ketamine

RADIODIAGNOSIS 283

Chapter 18 Radiodiagnosis

285) A. 2.5-5 Gy

285. Dose of radiation required for development of hematologicalsyndrome is: A. 2.5-5 Gy

B. 10 Gy

C. 100 Gy D. 200 Gy

Ref: Web. http://orise.orau.gov/reacts/guide/syndrome.htm

Exp:

Dose Syndromes associated Clinical features < 2 Gy A/c Radiation Syndrome Nausea, vomiting

No need of hospitalisation 2-8 Gy Haematopoietic Syndrome Death in 2-4wks due to

Bone marrow failure

> 10 Gy Gastrointestinal Syndrome Vomiting, Diarrhoea, SepsisDeath within days

> 30Gy Cardiovascular Syndrome Death within 48hrs

>100Gy Cerebrovascular Syndrome Death within 24-48hrs due to neurological & cardiovascular failure

(1 Gy = 100 cGy = 100 rad)


286. Aortic knuckle shadow on chest X-ray, PA view is obliterated byconsolidation of which portion of lung?

A. Upper lingula

B. Lower lingula

C. Apex of lower lobe

D. Posterior part of upper lobe

Ref: Thoracic Imaging by W.Richard Webb & Charles B. Higgins P.39 &

P.43, Fig 2-19

Exp:

On PA/AP chest radiograph, obscuration of specific contours can berelated to abnormalities in specific lobes.

· Right Superior mediastinum (SVC) = Right upper lobe

· Right heart border = Right middle lobe

(*Silhouette sign)

· Right hemidiaphragm = Right lowerlobe

· Left superior mediastinum = Left upper lobe

(aortic knuckle)

· Left heart border = Lingular segments ofleft upper lobe

(Silhouette sign)

· Left hemidiaphragm/ Desc. Aorta = Left lower lobe

286) D. Posterior part of upper lobe.

(*AIIMS May 2008)

PSYCHIATRY 291

293. A 40yr old female patient presented with depressed mood, loss ofappetite and no interest in surroundings for the past 1yr. There is associatedinsomnia. These symptoms followed soon after a business loss 1yrback.Which of the following statements is true regarding the managementof this patient? A. No treatment is necessary as it is due to business loss B. SSRI is the most efficacious of the available drugs

C. Antidepressant treatment is based on the side effect profile of the drugs D. Combination therapy of 2 anti depressant drugs Ref: Kaplan & Sadock’s 10th 559

Exp:

This lady is having depression, and needs antidepressant medication.Selection of Initial MedicationThe available antidepressants do not differ in overall efficacy, speed of

response, or long-term effectiveness.Antidepressants, however, do differ in their pharmacology, drug-druginteractions, short- and long-term side effects, likelihood of discontinuation

symptoms, and ease of dose adjustment.

Chapter 19 Psychiatry

293) C. Treatment is started based on the side effect profile


Selection of the initial treatment depends on:

· Chronicity of the condition

· Course of illness

· Family history of illness

· Treatment response

· Symptom severity

· Concurrent general medical or other psychiatric conditions

· Prior treatment responses to other acute phase treatments

· Potential drug interactions

· Patient preference

Side effects of TCA:

· Anticholinergic-C/I ed in glaucoma and BPH

· Alpha blocking-causes postural hypotension

· Sedation

· Seizure

· Wt.gain

Side effects of SSRIs:

· No anticholinergic,hypotensive & sedative side effects

· Causes diarrhea, wt. loss, insomnia, anxiety & sexual dysfunction

(PGI Dec 2007)

�MC side effect of SSRIs: Loose stools (AI 2006)


5. Neuroleptic malignant syndrome (AIIMS May 2004|PGI Dec 2005)

Life threatening complication of antipsychotic treatment characterised by

a/c dystonia, akinesia, altered sensorium, mutism, hyperthermia, sweating,

tachycardia & hypertension.Investigations: Leukocytosis & elevated CPK (AIIMS May 2006)

Rx: a. Stop the drug

b.Drug of choice: Dandrolene Other dugs: Bromocriptine, Amantadine (D2 agonists),

Benzodiazepines (for sedation)

c. Cooling d. Supportive measures

�Antipsychotic drugs with least extrapyramidal side effect: Clozapine

(PGI 2002)

rapid review aipgmee, 2011

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