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
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.
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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.
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
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
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.
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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 |
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|
- ambiguous
genitalia,
in some females, such that it can be initially difficult to determine sex
- early pubic hair and rapid growth in childhood
- precocious
puberty
or failure of puberty to occur (sexual
infantilism:
absent or delayed puberty)
- excessive facial
hair, virilization, and/or menstrual irregularity in adolescence
- infertility due to anovulation
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
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.
- CD8+ T cells bind epitopes that are
part of class I histocompatibility molecules. Almost all the cells of the body
express class I molecules.
- CD4+ T cells bind epitopes that are
part of class II histocompatibility molecules. Only specialized
antigen-presenting cells express class II molecules. These include:
- dendritic cells
- phagocytic cells like macrophages and
- B cells (most probably)
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.
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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
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. 0>
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 B₂
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
|
|
*
|
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