AIIMS NOV. 2011,AIPG 2012 & May 2012 Recall.


AIIMS NOV. 2011,AIPG 2012 & May 2012 Recall.

ENT
2.     Which of the following nerves has no sensory supply to the auricle? (AIPG 2012)
1)     Lesser occipital nerve
2)     Greater auricular nerve
3)     Auricular branch of vagus nerve
4)     Tympanic branch of glossopharyngeal nerve

Ans 4)     Tympanic branch of glossopharyngeal nerve
Ref:ENT ,P.L. Dhingra ,5th ed.

Anatomy of the sensory nerves of the external ear are shown in the image below.

                Anatomy of sensory nerves in the external ear.
•       The greater auricular nerve (option ‘4’) is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle.
•       The lesser occipital  nerve innervates a small portion of the helix.
•       The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus.
•       The auriculotemporal nerve is a branch of the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspect of the auricle.
•       The external auditory canal and tympanic membrane have separate innervation. Indications for anesthetizing these areas are distinct from those for performing an auricular block.


7.Which of the following is used for screeing of auditory function in neonate? (AIIMS MAY 12)
1)Otoacoustic emission
2)Auditory brainstem response(ABR)
3)Auditory steady state responsive
4)Eco G batteries
Ans. 1)Otoacoustic emission
 Ref. Disease of Ear,Nose & Throat-P.L.Dhingra 3rd ed.pg, Scott - Brown's Otorhinolaryngology and Head & Neck Surgery 4th edition. 

 Auditory Brainstem Response(ABR) or BERA (Brainstem Evoked Response Audiometry)
·        It is the investigation of choice for Neonate Auditory Functioning.
·        In normal subjects 7 waves are produced in first 10 milliseconds
·        The I,III & V waves are most stable & used for measurements.
·        The waves are studied for absolute latency,inter-wave latency & the amplitude.
Otoacoustic Emissions (OAE)
·        OAE is screening investigation of choice for Auditory Function.
·        It measure potentials by placing electrode in EAC and measuring potentials coming from Outer Hair cells.
·        this can also be used for newborns, but most commonly used in Noise induced hearing loss, ototoxicity and malingering. 







Forensic Medicine

Q.5 According to Human organ transplant act 1994 provision for  punishment of imprisonment  to erring doctor  is – (AIIMS NOV 2011)
1. less than 1 year
2.less than 2 year
3.2 to 5 year
4.more than 5 year
Ans . 4.more than 5 year
Ref. Transplantation of Human Organs Act 1994



Sec 18.Punishment for removal of human organ without authority
(1) Any person who renders his services to or at any hospital and who, for purposes of transplantation, conducts associates with, or helps in any manner in, the removal of any human organ or tissue or both without authority, shall be punishable with imprisonment for a term which may extend to ten years and with fine which may extend to five lakh rupees.
(2). Where any person convicted under sub-section (1) is a registered medical practitioner, his name shall be reported by the Appropriate Authority to the respective State Medical Council for taking necessary action including the removal of his name from the register of the Council for a period of three years for the first offence and permanently for the subsequent offence
So, punishment for erring doctor can be imprisoned for upto 10 years and fine of five lakh rupees, while the name of the doctor can be removed from the medical register for a period of 3 years for first offence and permanently for subsequent offence.

In comparison, the penalties under PCPNDT( Pre-Conception & Pre-Natal
Diagnostic Techniques Act) 1994 as follows:

(i)on Advertisement – of any of sex selection or sex determination techniques; 3 y + 10,000 Rs [s22]
(ii)on Sex selection of sex determination –
(a)To doctor – 1st conviction 3 y + 10,000 Rs. Subsequent convictions 5 y + 50,000 Rs [s23(1)]. On conviction, name will be removed from medical register for 5 y for 1st offence and permanently [professional death sentence] on 2nd offence [s23(2)]
 (b)To patient - 3 y + 50,000 Rs for 1st offence and 5 y + 100,000 Rs for 2nd offence [s23(3)]. If the woman was compelled she will not be punished [s23(4)], but the person compelling her would be.

MEDICINE

Q.14 A lady presents with complaints of abdominal pain. CECT shows B/L papillary necrosis. Which of the following test shall not be done to investigate the cause of her papillary necrosis?(AIIMS NOV 11)
1.Culture for bacteria
2.Sickling test
3.Urine acidification
4.Urine PCR for TB
Ans. 3.Urine acidification
Ref.Harrisons 18th ed.pg2372

MAJOR causes of Papillary necrosis-
·        Analgesic nephropathy
·        Sickle cell nephropathy
·        Diabetes with urinary tract infection
·        Prolonged NSAID use (rare)

Though TB is not a major cause but it can cause papillary necrosis.

Urine Acidification test is mainly done to diagnose RTA.

Bacterial Cultutre is done for UTI.
Sickle  cell disease can be diagnosed by sickling test.

So answer of choice is Urine acidification




4.    About fibromyalgia all are true except- (AIPG 2012)
1)     Associated with EEG abnormalities
2)     More common in males than females
3)     Associated with increased cortisol response
4)     Associated with decresed blood flow to brain

Ans: 2)     More common in males than females
3)     Associated with increased cortisol response

Ref. Harrisons 18th ed.pg 2849
·        The disordered sleep physiology in fibromyalgia has been identified as a sleep anomaly of alpha-wave intrusion, which occurs during NREM stage 4 sleep leading to EEG abnormalities (option ‘1’)
·        This intrusion into deep sleep causes the patient to awaken or to be aroused to a lighter level of sleep.
·        Central pain modulatory systems in females are influenced by phasic alterations in reproductive hormone levels.
·        Aversive stimuli and stressful tasks are more likely to evoke sympathetic nervous system, HPA axis, and psychological responses in females than in males; hence fibromyalgia is more common in females.

There are 5 main measurable neuroendocrine abnormalities are associated with dysfunction of the HPA axis seen in fibromyalgia. These include
·        Low free cortisol levels in 24-hour urine samples
·        Loss of the normal circadian rhythm, with an elevated evening cortisol level (when it should be at its lowest level)
·        Insulin-induced hypoglycemia associated with an overproduction of ACTH
·        Low levels of growth hormone
·        Stimulated ACTH secretion leading to insufficient adrenal release of glucocorticoids
·        Fibromyalgia is associated with decreased cortisol response to stress.





Q.2 Alzheimers disease all are seen except (AIIMS Nov11)
1). Aphasia
2) .Acalculia
3) .Apraxia
4) .Agnosia 
Ans.2.Acalculia.
Ref. Bradley Neurology 5th ed. CH.79,Pg No-1856.
DSM-IV Diagnostic criteria for Alzheimer's Disease (AD)
A. The development of multiple cognitive deficits manifested by both memory impairment and one or more of the following
  • Aphasia
  • Apraxia
  • Agnosia
  • and disturbances in executive functioning
B. The cognitive deficits represent as decline from previous functioning and cause significant impairment in social or occupational functioning
C. The course is characterized by gradual onset and continuing decline
D. The cognitive deficits are not due to other central nervous system, systemic, or substance-induced conditions that cause progressive deficits in memory and cognition
E. The disturbance is not better accounted for by another psychiatric disorder
So as per DSM IV criteria applied worldwide answer should be Acalculia as it does not figure out in the criteria.But interestingly if atall Agnosia is seen it is well seen in adavanced stages of disease not in early stages of disease.

Q17.A 60 year female presented with decreased movements for the last 2 years with rigidity and vertical square wave jerks. The most likely diagnosis is – (AIIMS may12)
        1)     Parkinson’s disease
        2)     Lewy body dementia
        3)     Multisystem atrophy
        4)     Progressive supranuclear palsy
Ans 4)      Progressive supranuclear palsy
Ref. Harrisons 18th ed.
Parkinsonism is a degenerative disorder caused by degeneration of substantia nigra pars compacta idiopathic in etiology commonly well  known as Parkinson disease.Its clinical feature is a love triangle of tremors,rigidity & bradykinesia.Something most essential or M.C is tremors which is missing in our question.So examiner probably wants to ask you about parkinsonism plus in which tremors go missing many more new features occur. They are-
1).Multiple sytem atrophy(MSA) –Patients present with bradykinesia with rigidity with prominent cerebellar signs(MSA-c) or without cerebellar signs only some signs of PK(MSA –p).Something essential or unique about them is autonomic dysfunction which is missing in our question.
2).Progressive supranuclear palsy (PSP) which is characterized by axial extended rigidity,Impairement of downward gaze with h/o recurrent falls(early feature) combines with dementia in late stages.In our question patient doesn’t seems to have recurrent falls.
3).Corticobasilar degeneration (CBD) less common manifests as asymmetric dystonic contractions ans clumsiness of one hand with cortical sensory disturbances-apraxia,agnosia,Myoclonus.Dementia may occur at any stage.
4).Lewy body dementia(LBD) –It is characterized by visual hallucinations,Parkinsonism,fluctuating alertness and falls.

Bradley’s neurology practice 5th ed.ch.38.pg no.719. quotes
“Square wave jerks(SWJ) are spontaneous small amplitude paired saccades with an intersaccadic latency of 150 to 200 msec that briefly interrupts fixation.They may occur physiologically in normal subjects(in darkness) without fixation and are usually about 2 degree in amplitude .SWJs are prominent in PSP,and cerebellar disease.”

Q.17aA 60 year female presented with decreased movements for the last 2 years with rigidity and LARGE square wave jerks. The most likely diagnosis is – (AIIMS may’12)
        1)     Parkinson’s disease
        2)     Lewy body dementia
        3)     Multisystem atrophy
        4)     Progressive supranuclear palsy
Ans  3)     Multisystem atrophy
Bradley’s neurology practice 5th ed.ch.38.pg no.719. quotes

“Square wave pulses are large square wave jerks of larger amplitude 10-40 degree.They are seen in patients with multiple sclerosis and olivopontocerebellar degeneration(OPCA).”
 
OPCA is now known as MSA.
So if we say a patient with rigidity,bradykinesia & large square wave jerk then best possible answer would be MSA.

Q.21        Episodic muscle weakness can be caused by all of the following except – (AIPG 2012)
        1)     Hypercalcemia
        2)     Channelopathies
        3)     Lambert-Eaton myasthenic syndrome
        4)     Hyper phosphatemia

Ans: 4)     Hyper phosphatemia
Ref:  Harrison’s ‘Principles of Internal Medicine’; 18/e, pg 150 Table 23-2.
 Causes of Episodic Generalized Weakness
1. Electrolyte disturbances, e.g., hypokalemia, hyperkalemia, hypercalcemia, hypernatremia, hyponatremia, hypophosphatemia, hypermagnesemia
2. Muscle disorders
a. Channelopathies (periodic paralyses)
b. Metabolic defects of muscle (impaired carbohydrate or fatty acid utilization; abnormal mitochondrial function)
3. Neuromuscular junction disorders
a. Myasthenia gravis
b. Lambert-Eaton myasthenic syndrome
4. Central nervous system disorders
a. Transient ischemic attacks of the brainstem
b. Transient global cerebral ischemia
c. Multiple sclerosis


D/D of episodic / intermittent muscle weakness:
·        Myasthenia gravis
·        Lambert-Eaton myasthenic syndrome
·        Periodic paralyses (channelopathies)
o   Hyperkalemic
o   Hypokalemia
o   Paramyotonia congenital
·        Metabolic energy deficiencies of glycolysis
o   Myophosphorylase deficiency
·        Metabolic energy deficiencies of fatty acid utilization
o   Carnitine palmitoyltransferase deficiency
·        Mitochondrial myopathies

D/D of persistent muscle weakness:
·        Muscular dystrophies
·        Mitochondrial myopathies
·        Toxic myopathies
·        Endocrine myopathies
·        Inclusion body myositis

Option (4): Hyperphosphatemia
Ref:  Harrison’s ‘Principles of Internal Medicine’; 18/e, pg 3089

·        The clinical consequences of acute, severe hyperphosphatemia are mainly due to the formation of widespread calcium phosphate precipitates and resulting hypocalcemia.
·        Thus, tetany, seizures, accelerated nephrocalcinosis (with renal failure, hyperkalemia, hyperuricemia and metabolic acidosis) and pulmonary or cardiac calcifications (including development of acute heart block) may occur.








OBSTETRICS & GYNAECOLOGY
Q.13 For an elective forceps delivery , all of the following are incorrect except –(AIIMS NOV 11)
1.The fetal head should be at station ‘0’
2.Forcep can be used for >15 degree head rotation from AP diameter          
3.Can be used in vertex, mentoanterior  & face presentation 
4. There should be no caput succedaneum

Answer. 3.Can be used in vertex, mentoanterior  & face presentation 
Ref.Dutta 6th ed.,chapter36,pg571
 For outlet forceps the following criteria should be fullfilled according to ACOG classification of forceps and vacuum delivery
1) scalp is visible at introitus without separating the labia
2) fetal skull has reached pelvic floor( station is at +3)
3) Sagittal suture is in  AP diameter
4) fetal head is at or on perineum
5) rotation does not exceed

Forceps can be used in the following conditions

1) preferred in fetal distress
2) can be applied on face with mentum anterior and after coming head of breech
3) can be applied on preterm foetus
4) can be applied if recent scalp blood sampling has been done
5) can be applied in IUFD
 At all these places vacuum on the other hand cannot be used.


5.     Shock just  after normal delivery, due to?(AIPG 2012)
1)  Amniotic fluid embolism
2)  PPH
3)  Uterine inversion
4)  Postpartum eclampsia
Ans. 3)  Uterine inversion > 2)  PPH

 Ref. Obstetrics D.C.Dutta 6th ed.page 411,421,422.
Both option (2)&(3) seems correct though the uterine inversion is very much acute but still its very rare condition and on other hand post-partum h’ge is having a incidence of 1% in hospital deliveries & much-more in non-institutional deliveries.

But in terms of time duration after delivery,uterine inversion is very much acute & occurs just after delivery.
 so the answer of choice here is Uterine inversion.



POSTPARTUM HAEMORRHAGE
DEFINITION-
“Any amount of bleeding from or into the genital tract following birth of the baby upto the end of the puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum haemorrhage”.
INCIDENCE-
 The incidence widely varies mainly because of lack of uniformity in the criteria used in definition and the extent of the use prophylactic ergometrine. The incidence is about 1% amongst hospital deliveries.
TYPE:
·        Primary
·        Secondary
Primary: Haemorrhage occurs within 24 hours following the birth of the baby. In the majority, haemorrhage occurs within two hours following delivery.
These are of two types:
* Third stage haemorrhage- Bleeding occurs before expulsion of placenta.
* True postpartum haemorrhage- Bleeding occurs subsequent to expulsion of placenta (majority)
Secondary: Haemorrhage occurs beyond 24 hours and within puerperium, also called delayed or late puerperal haemorrhage.
PRIMARY POSTPARTUM HAEMORRHAGE
Causes-
* Atonic    *Traumatic       *Mixed     *Blood coagulpathy
Atonic uterus (80%):
Atonicity of the uterus is the commonest cause of postpartum haemorrhage. As long as the placenta remains unseparated, bleeding is unlikely. With the separation of the placenta, the uterine sinuses which are torn cannot be compressed effectively due to imperfect contraction and retraction of the uterus and bleeding continues.
.
INVERSION OF THE UTERUS
It is an extremely rare but a life threatening complication in third stage in which the uterus is turned inside out partially or completely. The incidence is about 1 in 20,000 deliveries. The obsertric inversion is almost always an acute one and usually complete.
VARIETIES-
First degree- There is dimpling of the fundus which still remains above the level of internal os.
Second degree- The fundus passes through the cervix but lies inside the vagina.
Third degree(complete)- The endometrium with or without the attaced placenta is visible outside the vulva. The cervix and part of the vagina may also be involved in the process.
ETIOLOGY: The inversion may be spontaneous or more commonly induced.
Spontaneous(40%): This is brought about by localized atony on the placental site over the fundus associated with sharp rise of intra abdominal pressure as in coughing, sneezing or bearing down effort. Fundal attachment of the placenta (75%) short cord and placenta accreta are often associated.
Iatrogenic: This is due to the mismanagement of third stage of labour.
-         Pulling the cord when the Uterus is atonic specially when combined with fundal pressure.
-         Crede’s expression while the uterus is relaxed.
-         Faulty technique in manual removal.
Q.7  A 20 year old average weight  female complains of oligomenorrhea along with facial hair. Preliminary investigations reveal raised free testosterone levels.USG Pelvis: ovary shows normal morphology. Which of the folllowing could be likely etiology? (AIIMS MAY 12)
1) Idiopathic hirsutism
2) PCOD
3) Adrenal hyperplasia
4) Testosterone secreting tumor
Ans. 2) PCOD

Ref. Oxford  Journals of  Medicine ,Volume 18, Issue 4 ,Pg. 896-897


In all above condition patient presents with hirsutism.
FERIMAN – GALLWAY SCORING is used for hirsutism

Idiopathic hirsutism
 Idiopathic hirsutism can be defined as excess terminal hair production in a male-like pattern in androgen-receptive body parts of patients who show no signs of endocrine or androgen disorders. This kind of hirsutism occurs in the presence of regular ovulation and normal androgen levels.

PCOD -  oligomenorrhea & hyperandrogenism seen.




Polycystic ovary syndrome: a simplified approach based on the evolving set of symptoms





Major criteria
Minor criteria
Anovulation
Polycystic ovaries on USG
Oligomenorrhea
Elevated LH/FSH ratio
Hyperandrogenism
Acne
Severe hirsutism
Mild Hirsutism
Insulin Resistance
Obesity


While the presence of one minor criterion suggests a tendency for PCOS, the presence of two minor criteria would suggest a mild form of PCOS. Furthermore, the presence of one major and one minor criterion, or one or more major and two or more minor criteria would indicate moderate or severe forms of PCOS respectively.

In above Q Patient is having
·        Oligomenorrhea- Major criteria
·        facial hair- Major or minor criteria
·        raised free testosterone levels- i.e. Hyperandrogenism –Major criteria
So patient is presenting with Two major & one minor  criteria which indicates severe PCOS.
Rotterdam criteria
·        Menstrual irregularity due to anovulation or oligoovulation
·        Hyperandrogenism- clinical / biochemical
·        Polycystic ovaries by USG- >12 follicles in each ovary,2- 9mm or ovarian volume >10mm
CLINICAL FEATURES
·         Menstrual disturbances 80%
·         Hirsutism 70%
·         Obesity 60%
·         Insulin resistance 50%
·         Infertility 60%
Association with PCOD
HAIR-AN Syndrome
Hyperandrogenism
Insulin resistance
Acanthosis nigricans
Pathophysiology of Polycystic Ovary Syndrome
·         LH Hypothesis
·         Insulin Hypothesis
·         Ovarian Hypothesis


In testosterone producing tumor  USG findings won’t be normal.
Adrenal hyperplasia-
These conditions involve excessive or deficient production of sex steroids and can alter development of primary or secondary sex characteristics in some affected infants, children, or adults. on USG ovaries are normal
Due to excess androgens:
2.Test used to differentiate b/w maternal  and fetal blood ? (may 12)
1)  Kleihauer Betke test
2)  Osmotic fragility test
3)  Apt test
4)  Bubblin test
Ans.   3)  Apt test
Ref. Obstetrics D.C.Dutta 6th ed.page.652

DETECTION OF FETAL HAEMOGLOBIN FROM VAGINAL BLEEDING (in case of antepartum haemorrhage)
Alkali denaturation test (Singer’s test): Blood to be sent – 2ml blood is to be collected from the vagina in an E.D.T.A-vial.
Detection of fetal red cells in the maternal blood (in case of Rh-isoimmunization)-
Modified Kleihauer-betke acid elution test
Blood to be sent – A blood films is drawn over a dry slide from maternal blood. The slide is fixed by immersing it in a solution of ethanol (80%) for three minutes and after drying in air, it is to be sent to the laboratory.
Alternatively – 2ml of maternal venous blood may be sent to laboratory in an E.D.T.A-vial.

APT Test/Swallowed Blood Syndrome Test-
·        This test is done to diagnose swallowed blood syndrome and differentiate this condition from gastrointestinal hemorrhage in the new born.
·        This test uses alkali denaturation of fetal hemoglobin to determine if blood is present in the stool of a newborn as a result of swallowing maternal blood or is due to perinatal or neonatal Gastro-intestinal hemorrhage.
·         In swallowed blood syndrome, blood or bloody stools are passed usually on the second or third day of life.
·        The blood may be swallowed during delivery or may be from a fissure of the mother’s nipple.
 The test is based on the fact that the infant’s blood contains > 60% fetal hemoglobin that is alkali resistant. Swallowed blood of maternal origin contains adult hemoglobin, which is converted to brownish alkaline hematin on the addition of alkali.

So the conclusion is
·        To differentiate maternal & fetal blood – APT Test.
·        To detect Fetal RBC in Maternal Blood- Kleihauer-betke acid elution test


PAEDIATRICS

1.     What is the pathology of edema in nephrotic syndrome?
1)     Reduced plasma protein (May 12)
2)     Sodium water retention
3)     Increased venous pressure
4)     Hyperlipidemia

Ans: 2)     Sodium water retention
         Ref: The pathophysiology of edema formation in the nephrotic syndrome
                       Eric J. Siddall and Jai Radhakrishnan
The nephrotic syndrome is characterized by proteinuria, edema, and hypoalbuminemia. Renal sodium retention and changes in variables of the Starling equation are fundamental to the pathophysiology of nephrotic edema.

There is evidence for both intravascular volume expansion (overfilling) and intravascular volume depletion (underfilling) in patients with nephrosis. Microvascular fluid exchange is described using a formulation of the Starling driving forces (DP and Dp) and it is through this equation that nephrotic edema is conceptualized.

Previous theories have focused on abnormalities in DP and Dp to explain nephrotic edema. Studies
have shown that hypoalbuminemia (and thus Dp) is not a likely cause of edema formation in most nephrotic patients owing to a parallel decrease in interstitial fluid albumin and an increase in interstitial fluid pressure, both of which serve to maintain edema driving forces constant.

 Thereis limited evidence suggesting that abnormalities in vascular permeability (Kf and s) may contribute to edema formation.

A major advance in our understanding of the pathophysiologic basis of edema formation in the nephrotic syndrome is the discovery that proteinuria can cause primary renal sodium retention through ENaC activation. This mechanism is likely active in all patients with nephrotic syndrome, regardless of their intravascular volume status.
 Other causes of primary renal sodium retention include increased renal efferent sympathetic nerve activity, ANP, and in the expression and activity of the Na/K ATPase in the collecting duct in animal models .

 Furthermore, excess serum vasopressin levels have been found to contribute to free water retention in some patients with the nephrotic syndrome. It is not clear if nephrotic proteinuria underlies any of these other
abnormalities. The renin–angiotensin–aldosterone system does not appear to be a primary mechanism of renal sodium retention.


Mechanisms of sodium retention in the nephrotic  syndrome-
 (1) Increased angiotensin II-independent afferent and efferent arteriolar tone because of increased efferent sympathetic nerve activity.
 (2) Tubular resistance to atrial natriuretic peptide (ANP).
(3) Increased number of open epithelial sodium channel (ENaC) channels in the cortical collecting duct due to proteolytic activation of ENaC by plasmin.
 (4) Increased number and activity of cortical collecting duct Na/K ATPase channels. SNS, sympathetic
nervous system.


PATH  NOV 11

23.     B and T lymphocytes share all the features except –
          1)       Positive selection during development
          2)       Class I MHC expression
          3)       Antigen specific receptors
          4)       Dependence on cytokines secreted by other cells
Ans. 4)       Dependence on cytokines secreted by other cells  
Ref.http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/B/B_and_Tcells.
B & T cells share all features except answer is dependent on cytokines secreted by other cells. T cells are the ones which secrete cytokines and B cells are dependent on these cytokines for their function thus they differ in this feature. Only B cells are dependent on cytokines secreted by other cells where as T cells are dependent on cytokines secreted by themselves. About the other options express MHC class I antigens this is true because both B and T cells are nucleated cells and thus both express class I antigens.
PHYSIO nov 11

5.     Self-stimulation could be induced experimentally most effectively from which part of brain ? (AIPG 2012)
          1)   Periaqueductal area (Area around the aqueduct of Sylvius)
         2)    Periventricular region of hypothalamus
          3)   Medial forebrain bundle
         4)    Mesencephalon

Ans: 3)    Medial forebrain bundle
Ref. Ganong Physiology 23rd edition,Chap.Neural basis of instinctual behaviour.

The points where stimulation leads to repeated bar pressing are located in a medial band of tissue extending from the ventral tegmentum to the frontal cortex . The most responsive area is the dopaminergic pathway from the ventral tegmental area to the nucleus accumbens (see below). The points where stimulation is avoided are in the lateral portion of the posterior hypothalamus, the dorsal midbrain, and the entorhinal cortex.


Table - Areas Where Stimulation Leads to Repeated Bar Pressing.
Ventral tegmentum
Medial forebrain bundle
Nucleus accumbens
Frontal cortex

They generally report that the sensations evoked are pleasurable, using phrases like "relief of tension" and "a quiet, relaxed feeling" to describe the experience. However, they rarely report "joy" or "ecstasy," and some persons with the highest self-stimulation rates cannot tell why they keep pushing the bar.

Drugs that block postsynaptic D3 dopaminergic receptors reduce the rate of self-stimulation, and dopamine agonists increase it. The main site of the relevant receptors is the nucleus accumbens located at the base of the striatum.



PSM
9.     The amount of alcohol consumption by a group, pre- and post-intervention was recorded. To determine whether there is a significant difference in alcohol consumption after intervention is seen or not, best test would be- (NOV 11)
        1)     Paired ‘t’ test
        2)     Unpaired ‘t’ test
        3)     McNemar test
        4)     Chi-square test

Ans: 1)     Paired ‘t’ test 
Ref:  Read the text below


Goal
Type of data
Ratio and interval data which
follows normal distribution
Ratio and interval data which does not follows normal distribution
and ordinal data (rank and scores)
Nominal data
Describe one group
Mean, SD
Median, interquartile range
Proportion
Compare one group to a hypothetical value
One-sample t test
Wilcoxon test
Chi-square
or
Binomial test
Compare two unpaired groups
Unpaired t test
Mann-Whitney test
Fisher's test
(chi-square for
large samples)
Compare two paired groups
Paired t test
Wilcoxon test
McNemar's test
Compare three or more unmatched groups
One-way ANOVA
Kruskal-Wallis test
Chi-square test
Compare three or more matched groups
Repeated-measures ANOVA
Friedman test
Cochrane Q
Quantify association between two variables
Pearson correlation
Spearman correlation
Contingency
coefficients
Predict value from another measured variable
Simple linear regression
or
Nonlinear regression
Nonparametric regression
Simple logistic
regression
Predict value from several measured or binomial variables
Multiple linear regression
or
Multiple nonlinear regression

Multiple logistic regression

So, in the question, when mean alcohol consumption is to be compared the answer will be paired t test, but if the question would have been asking proportion/percentage of people consuming alcohol before and after the intervention, the answer would have been Mc Nemar test.


·        In statistics, McNemar's test is a non-parametric method used on nominal data.
·        It is applied to 2 × 2 contingency tables with a dichotomous trait, with matched pairs of subjects, to determine whether the row and column marginal frequencies are equal ("marginal homogeneity").
·        It is named after Quinn McNemar, who introduced it in 1947.

Example:
A researcher attempts to determine if a drug has an effect on a particular disease.
Counts of individuals are given in the table, with the diagnosis (disease: present or absent) before treatment given in the rows, and the diagnosis after treatment in the columns.
The test requires the same subjects to be included in the before-and-after measurements (matched pairs).


After:present
After:absent
Row total
Before:present
101
121
222
Before:absent
59
33
92
Column total
160
154
314

In this example, the null hypothesis of "marginal homogeneity" would mean there was no effect of the treatment.
From the above data, the McNemar test statistic with Yates's continuity correction has the value 21.01, which is extremely unlikely from the distribution implied by the null hypothesis.
Thus the test provides strong evidence to reject the null hypothesis of no treatment effect.

Psychiatry
5. A 35-year female has been diagnosed with obsessive compulsive disorder and she washes her hands many times a day. Which would be the best CBT technique for her treatment? (AIPG 2012 )
          1)       Thought stopping
          2)       Response prevention
          3)       Relaxation
          4)       Exposure

Ans: 2)       Response prevention > 4)       Exposure
Ref:  Harrison’s ‘Principles of Internal Medicine’; 18/e, chapter 391

OBSESSIVE-COMPULSIVE DISORDER:
·        Obsessive-compulsive disorder (OCD) is characterized by obsessive thoughts and compulsive behaviors that impair everyday functioning.
·        Fears of contamination and germs are common, as are handwashing, counting behaviors, and having to check and recheck such actions as whether a door is locked.
·        The degree to which the disorder is disruptive for the individual varies, but in all cases obsessive-compulsive activities take up >1 hour per day and are undertaken to relieve the anxiety triggered by the core fear.
·        Patients often conceal their symptoms, usually because they are embarrassed by the content of their thoughts or the nature of their actions.
·        A genomewide association study (GWAS) reported linkage to chromosome 2p23.2; however, no susceptibility gene for OCD has been identified to date.
·        Family studies show an aggregation of OCD with Tourette's disorder, and both are more common in males and in first-born children.

Treatment:
·        Clomipramine, fluoxetine, fluvoxamine, and sertraline are approved for the treatment of OCD.
·        Clomipramine is a TCA that is often tolerated poorly owing to anticholinergic and sedative side effects at the doses required to treat the illness (25–250 mg/d); its efficacy in OCD is unrelated to its antidepressant activity.
·        Fluoxetine (5–60 mg/d), fluvoxamine (25–300 mg/d), and sertraline (50–150 mg/d) are as effective as clomipramine and have a more benign side effect profile.
·        Only 50–60% of patients with OCD show adequate improvement with pharmacotherapy alone.
·        In treatment-resistant cases, augmentation with other serotonergic agents such as buspirone, or with a neuroleptic or benzodiazepine may be beneficial and in severe cases deep brain stimulation has been found to be effective.
·        When a therapeutic response is achieved, long-duration maintenance therapy is usually indicated.
·        For many individuals, particularly those with time-consuming compulsions, behavior therapy will result in as much improvement as that afforded by medication.
·        Effective techniques include the gradual increase in exposure to stressful situations & Response prevention, maintenance of a diary to clarify stressors, and homework assignments that substitute new activities for compulsive behaviors.

2 The diagnostic feature that differentiates PTSD from other disorders that occur following a stressful incident is – (may 12)
        1)     Episodic occurrence of symptoms
        2)     Severe anxiety and autonomic arousal
        3)     Re-experiencing and avoidance of trauma
        4)     Nightmares about the event
Ans.  3)    Re-experiencing and avoidance of trauma
Ref.Various Journals & articles.

Ideally option (2),(3) & (4) are correct,but if we have to choose one then best is option (3)    Re-experiencing and avoidance of trauma

The diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) (DSM-IV-TR), may be summarized as-

A: Exposure to a traumatic event

This must have involved both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror, or helplessness (or in children, the response must involve disorganized or agitated behavior). (The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience.")

B: Persistent re-experiencing

One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).

C: Persistent avoidance and emotional numbing

This involves a sufficient level of:
  • avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
  • avoidance of behaviors, places, or people that might lead to distressing memories;
  • inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
  • decreased capacity (down to complete inability) to feel certain feelings;
  • an expectation that one's future will be somehow constrained in ways not normal to other people.

D: Persistent symptoms of increased arousal not present before

These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance.

E: Duration of symptoms for more than 1 month

If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.

F: Significant impairment

The symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity, such as social relations, occupational activities, or other "important areas of functioning".
Surgery
Q.11 With reference to peripheral vascular disease, all of the following statements are true except– ( nov 11)
1.Ankle-brachial pressure index < 0.5 indicates critical limb ischaemia
2.Ankle-brachial pressure index is different at rest than that during exercise
3.L-arginine is useful for providing endothelium-independent vasorelaxation/vasodilation
4.Smoking has a greater association with peripheral vascular disease than coronary vascular disease
Ans. 4.Smoking has a greater association with peripheral vascular disease than coronary vascular disease  > 3.L-arginine is useful for providing endothelium-independent vasorelaxation/vasodilation


Ref. SRB’s MANUAL OF SURGERY 3RD ed.page,150,Harrison 18th  pg.2047
Option 4 & option 3 both seems correct
·      smoking has greater association with coronary artery disease than peripheral vascular disease.


The ankle–brachial pressure index (ABPI) is the ratio of systolic pressure at the ankle to that in the arm. The higher of the pressures in the dorsalis pedis and posterior tibial arteries serves as the numerator, with the higher systolic pressure between the brachials serving as the denominator.
 Resting ABPI is normally about 1.0; values below 0.9 indicate some degree of arterial obstruction and less than 0.3 suggests imminent necrosis.
Some Authors are of opinion that ABPI values 0.3-0.5 is suggestive of critical limb ischemia.
 Retesting after exercise is useful in this context as ABPI normally rises but occlusive disease may result in reduction.
Artefacts are due especially to calcified arteries, which are often incompressible and lead to a falsely high pressure or ABPI result, especially in diabetics.

Harrison-18th  --------- An  ankle branchial index <0 .9=".9" amp="amp" artery="artery" associated="associated" considered="considered" diagnostic="diagnostic" disease="disease" is="is" nbsp="nbsp" of="of" peripheral="peripheral" with="with"> 50% stenosis in atleast one major lower limb vessel.

L-Argeinine is a precursor of Nitric oxide so helps in vasodilatation.

4.     Which of following carcinoma has highest chances of metastasis to spleen? (AIPG 2012)
        1)     Pancreas
        2)     Stomach
        3)     Ovary
        4)     Cervix

Ans: 2)     Stomach

Ref:  Lam K Y and Tang V. Metastatic Tumors to the Spleen: A 25-Year Clinicopathologic Study. Archives of Pathology and Laboratory Medicine. 2000;124:526–530.

·        Ninety-five percent (87 cases) of the metastatic lesions to the spleen were carcinomas.
·        Relatively common primary sites of carcinomas included the lung (n = 19), stomach (n = 15), pancreas (n = 11), liver (n = 9), colon (n = 8), and esophagus (n = 7).
·        Primary lesions were also seen in the upper respiratory tract (nasopharynx and larynx), breast, female genital tract (ovary, placenta, and cervix), gall bladder, and kidney.

Ref:  Ghani A A, Hashmi Z A, et al. Intraparenchymal metastases to the spleen from ovarian cancer: a case report. Journal of Medical Case Reports 2010, 4:30

·        Metastatic carcinoma to the spleen is unusual.
·        Cancers of the lung, breast, skin, ovary, colon, and stomach are the most common primary sites, with lung being the most frequent.
·        Visceral metastases in patients with ovarian cancer represent hematogenous spread of the disease, and are present in 2% to 3% of patients.
·        In most cases, the spleen is involved as part of a diffuse carcinomatosis, and splenic metastasis reflects widespread tumor dissemination.
·        Warren and Davis reported that the incidence of metastases to the spleen ranged from 0.3% to 4.8%, based on autopsy reports

Ref:  Showalter S L, Hager E and Yeo C J. Metastatic Disease to the Pancreas and Spleen. Department of Surgery Faculty Papers & Presentations. 2008; Paper 13

·        The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian.
·        Berge et al found the spleen to be the tenth most common site of metastasis, with an incidence of neoplastic involvement in 7.1% of autopsy cases of cancer patients.
·        Although splenic involvement is seen fairly often, isolated metastases to the spleen are exceedingly rare.
·        In 2001, Agha-Mohammadi et al reported a series of 54 patients, and found the most common primary neoplasms to be gynecologic (61%), colorectal (15%), lung (9%), and stomach (4%).
·        As with other cancers, splenic involvement from ovarian or endometrial cancers typically signifies late disseminated disease.

Thus, the most common cause of splenic metastases is lung carcinoma.

 However, in above Q the conclusion is If known primaries is there than stomach is answer of choice for splenic metastasis.

In case splenic secondaries without known primary answer should be ovary .

It seems answer of choice is stomach here.

DERMATOLOGY

1.     A 27 year old sexually active wife of a long distance truck driver presented with copious vaginal discharge of 2 days duration. According to the syndromal management of vaginal discharge, which of the following would be given to her?(MAY 12)
        1)     Azithromycin + Metronidazole + Fluconazole
        2)     Azithromycin
        3)     Metronidazole + Fluconazole
        4)     Fluconazole

Answer: 3) Metronidazole + Fluconazole

Etiology of vaginal discharge include candida, Trichomonas vaginalis and bacterial vaginosis. Accordingly, the treatment should include fluconazole for candida and metronidazole/ secnidazole for trichomonas and bacterial vaginosis. Cervical discharge on the other hand are caused by gonorrhea or chlamydia and are treated with cefixime and azithromycin

Syndromic management of STIs
Kit No./ Colour
Syndrome
Contents
Kit 1 Grey
Urethral Discharge, Anorectal discharge, Cervicitis
Tab. Azithromycin 1 g (1)
and Tab. Cefixime 400 mg (1)

Kit 2 Green
Vaginitis
Tab. Secnidazole 2 g (1) or metronidazole
and Tab. Fluconazole 150 mg (1)

Kit 3 White
Genital ulcer disease(GUD)
Inj. Benzathine penicillin 2.4 MU (1)
and Tab. Azithromycin 1 g (1)
and Disposable syringe 10 ml with 21 gauge needle (1)

Kit 4 Blue
GUD
Tab. Doxycycline 100 mg (30)
and Tab. Azithromycin 1 g (1)

Kit 5 Red
GUD
Tab. Acyclovir 400 mg (21)

Kit 6 Yellow
Lower abdominal pain
Tab. Cefixime 400 mg (1)
and tab. Metronidazole 400 mg (28)
and Cap. Doxycycline 100 mg (28)

Kit 7 Black
Inguinal bubo
Tab. Doxycycline 100mg (42)
and Tab. Azithromycin 1 g (1)

[Figures in brackets indicate the number of injections, tablets or capsules provided in the kit]

Microbiology
14.   Bacterial resistance to antibiotics is a genetic event that is located in which part of the bacterial cell? (AIPG 2012)
        1)     Chromosome
        2)     Intron
        3)     Plasmid
        4)     Centromere

Ans: 3)     Plasmid
Ref:  Ananthanarayan & Panicker’s ‘Textbook of Microbiology’; 8/e, pg 67
       Goodman & Gilman’s ‘The Pharmacological Basis of Therapeutics’,12/e, pg 1377-1378

·        Drug resistance may be acquired by mutation and selection, with the passage of the trait vertically to daughter cells.
·        For mutation and selection to be successful in generating resistance, the mutation cannot be lethal and should not appreciably alter virulence.
·        Drug resistance is more commonly acquired by horizontal transfer of resistance determinants from a donor cell, often of another bacterial species, by transformation, transduction or conjugation.
·        It is greatly facilitated by and largely dependent up on mobile genetic elements such as plasmids and transducing phages.
·        Other mobile elements – transposable elements, integrons and gene cassettes – also participate in the process.

Bacteria may acquire drug resistance by mutation or by one of the methods of genetic transfer.

Mutational drug resistance
Transferable resistance
One drug resistance at a time
Multiple drug resistance
Low degree resistance
High degree of resistance
Can be overcome by high drug dose
Cannot be overcome even by high drug dose
Drug combinations can prevent
Drug combinations cannot prevent
Resistance does not spread
Resistance spreads to same or different species
Mutants may be defective
Mutants are not defective
Virulence may be low
Virulence is high

PHARMACOLOGY

AI 12

13.   Platelet therapy is usually given for patients with stroke, MI and peripheral vascular disease. PPIs are frequently administered along with these drugs to prevent the risk of increased gastrointestinal erosions and bleeding. The interaction between clopidogrel and PPI has recently been given much attention due to its clinical significance. The metabolizing enzyme common to these two drugs is –
        1)     CYP2C10
        2)     CYPA2
        3)     CYPB2
        4)     CYP2C20

Ans: None of these
Ref:  Goodman & Gilman’s ‘The Pharmacological Basis of Therapeutics’; 12/e, pg 870

·        There is wide inter-individual variability in the capacity of clopidogrel to inhibit ADP-induced platelet aggregation.
·        This variability reflects, in part at least, genetic polymorphisms in the CYPs involved in the metabolic activation of clopidogrel, most importantly, CYP2C19.
·        Concomitant administration of proton pump inhibitors, which are inhibitors of CYP2C19, with clopidogrel, produces a small reduction in the inhibitory effects of clopidogrel on ADP-induced platelet aggregation.
·        The extent to which this increases the risk of cardiovascular events remains controversial.
·        Although CYP3A4 also contributes to the metabolic activation of clopidogrel, polymorphisms in this enzyme do not appear to influence clopidogrel responsiveness.
·        However, a small study in patients undergoing PCI revealed that atorvastatin, a competitive inhibitor of CYP3A4, reduced the inhibitory effect of clopidogrel on ADP-induced platelet aggregation. The impact of this interaction on clinical outcomes is unknown.

[Please note: It has nowhere been mentioned in literature that CYP2C10 or CYP2C20 metabolizes clopidogrel. In all text books and journals, the enzyme mentioned is CYP2C19. CYPA2 (option ‘3’) and CYPB2 (option ‘2’) are enzymes belonging to classes different from CYP2C19; whereas CYP2C8/9 has been mentioned as a different enzyme metabolizing its own set of drugs and molecules. And it has been confirmed by asking a large number of students who had appeared for this exam that CYP2C19 was never given amongst the options.]

31.   An elderly male suffering from allergic conjunctivitis, uses a drug that prevents the release of chemical mediators from mast cells. Which of the following drug has above action-
        1)     Inhibition of 5-lipoxygenase
        2)     Blockade of muscarinic receptors
        3)     Activation of B receptors
        4)     Blockade of calcium influx
     
Ans: 4)     Blockade of calcium influx
Reference: http://en.wikipedia.org/wiki/Ketotifen

Ketotifen:
·        Mainly a H1 antagonist
·        Additional leukotriene antagonist and phosphodiesterase inhibitor action

Inhibits PDE enzyme
Increase in cAMP
Inhibits calcium influx into the cells
Prevents degranulation of mast cells

Pharmacokinetics:
·        Given orally, topically
·        Oral bioavailability good
·        Plasma protein binding high
·        T½: 12 h
·        Metabolized by liver

Indications:
·        Prophylaxis of asthma attacks
·        Allergic rhinitis
·        Allergic conjunctivitis

ADR:
·        Drowsiness
·        Weight gain
·        Dry mouth
·        Irritability
·        Increased nosebleeds

MAY 12

4.     A 25 year old person with history of repeated episodes of rheumatic fever is hypersensitive to penicillin. Which of the following drug can be prescribed to him?
1)     Penicillin G
2)     Sulfisoxazole
3)     Sulfasalazine
4)     Streptomycin

Ans: 2)     Sulfisoxazole

Ref:  Braunwald’s Heart Disease, 9th Ed.

Initial Treatment of Group A Beta-Hemolytic Streptococcal Pharyngitis (Adult Dosages)
ANTIBIOTIC
DOSE
FREQUENCY
DURATION
COMMENTS
CLASS
Benzathine penicillin G
1.2 million units IM
One time
Acutely only
↓ Compliance issues
↑ Pain
I
Penicillin V
500 mg PO
Twice daily
10 days
I
Amoxicillin
1000 mg PO
Daily
10 days
I
Penicillin Allergic
Narrow-spectrum cephalosporins*
Varies by drug
Varies by drug
10 days
Avoid if history of anaphylaxis secondary to penicillin
I
Clindamycin*,[†]
300 mg PO
Twice daily
10 days
IIa
Azithromycin*,[‡]
500 mg PO day 1
250 mg PO days 2-5
Daily
5 days
IIa
Clarithromycin*,[‡]
250 mg PO
Twice daily
10 days
IIa

Secondary Prophylaxis Regimen for Patients with Documented RF (Adult Dosages)[?]
ANTIBIOTIC
DOSE
FREQUENCY
COMMENTS
CLASS
Benzathine penicillin G
1.2 million units IM
Every 3 to 4 weeks[?]
↓ Compliance issues
↑ Pain
I
Penicillin V
250 mg PO
Twice daily
I
Erythromycin*,[‡]
250 mg PO
Twice daily
I
Sulfadiazine*
1 g PO
Daily
I
Sulfisoxazole*
1 g PO
Daily
IIa
*
Alternative for penicillin-allergic patients. Erythromycin for secondary prophylaxis is an alternative for patients allergic to both penicillin and sulfa.

1 comment:

Chase Howard said...

Thanks for sharing this information! I have been looking into getting autonomic testing because I have recently been diagnosed with hyperhydrosis, which is excessive sweating, which, as you know, is an autonomic dysfunction. Have you done any tests on that?

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