Q-1. A 65 year old female Kamala gives the history of severe unilateral headache on the right side and complains of blindness since 2 days. On examination there is a thick cord like structure on the lateral side of the head. The ESR is 80 mm/Hr in the first hour. The most likely diagnosis is
a) Temporal arteritis
b) Migraine
c) Cluster headache
d) Sinusitis
Ans: Temporal arteritis
Explanation:
Headache is the most common chief complaint and presents in over two thirds of patients with temporal arteritis.
Superficial temporal artery involvement can lead to severe scalp tenderness during such simple acts as resting the head on a pillow, combing hair, or wearing hats and eyeglasses. Patients may also present with visible areas of scalp necrosis.
Similarly, jaw claudication while speaking or chewing is observed in patients with involvement of the maxillary artery, which can occur in half of patients with temporal arteritis.
Visual loss may also be a presenting symptom and can be sudden and painless. Initial visual symptoms are usually transient and intermittent, typically manifesting as unilateral visual loss or occasionally diplopia. However, if left untreated, permanent blindness frequently results.
Most patients with temporal arteritis have an ESR greater than 80 mm/h. However, up to 20% of patients with temporal arteritis may have a normal or low ESR, and thus a normal ESR level cannot exclude a diagnosis of temporal arteritis. CRP has been found to be elevated in patients with temporal arteritis, even in patients with a normal ESR.
Q-2. Renal damage due to Amphotericin B are all except
a) Azotemia
b) Renal tubular acidosis
c) Glomerulo-nephritis
d) Hypo-kalemia
Ans: c
Explanation:
Amphotericin B-induced nephro-toxicity is manifested as azotaemia, renal tubular acidosis, impaired renal concentrating ability and electrolyte abnormalities like hypo-kalemia and sodium and magnesium wasting. All these abnormalities occur to varying degrees in almost all patients receiving the drug. Upon withdrawal of therapy renal function gradually returns to baseline, although in some instances permanent damage is sustained.
Q-3. For comparison grading of pain the scale used is
a) Face’s scale
b) CHEOPES
c) Numerical charts
d) Visual scale
Ans: d
Explanation:
The visual analog and numeric rating scales are simple reporting instruments that can accurately quantify a patient’s subjective pain for the clinician.
The validity of the 10 centimeter visual analog scale has been established and there is evidence that the 10 centimeter scale graded into one centimeter intervals with small markings on the horizontal line is more reliable.
Q-4. Narcolepsy is characterized by all of the following except
a) Sleep paralysis
b) Cataplexy
c) Hallucination
d) Snoring
Ans: Snoring
Explanation:
Narcolepsy is a sleep disorder that causes excessive sleepiness and frequent daytime sleep attacks. Narcolepsy symptoms usually first occur during ages 15 to 30.
Symptoms:
Periods of extreme drowsiness during the day
Sleep paralysis
Cataplexy- A sudden loss of muscle tone while awake that makes you unable to move
Hallucinations: Hypnogogic and hypnopompic hallucination
Multiple Sleep Latency Test (MSLT) to see how long it takes you to fall asleep during a daytime nap.
Q-5. A high amylase level in pleural fluid suggests a diagnosis of
a) Malignancy
b) Tuberculosis
c) Rheumatoid arthritis
d) Pulmonary infarct
Ans: a
Explanation:
Amylase levels elevated in pleural effusions are found in three categories- Pancreatitis with or without pseudo-cyst formation or a direct pancreatic-pleural fistula, rupture of the esophagus, malignancy. Lung cancer and adeno-carcinoma are the most common tumor and histologic type associated with high amylase level in pleural fluid.
Q-6. A normal anion gap metabolic acidosis occurs in patients with
a) Diarrhoea
b) Diabetic keto-acidosis
c) Methyl alcohol poisoning
d) Acute renal failure
Ans: a
Explanation:
Causes of non-anionic gap acidosis
Gastrointestinal bicarbonate loss
Diarrhoea
External pancreatic or small bowel drainage
Drugs induced diarrhoea- Magnesium sulfate and cholestyramine
Acidifying agent- Calcium carbonate
Renal acidosis
Hyper-kalemia
Hypo-kalemia
Drugs induced hyper-kalemia
Potassium sparing diuretics
Trimethoprim
ACE inhibitors and AT-II receptor blockers
NSAID
Other
Rapid saline administration
Q-7. Carcinoid tumor is most common in
a) Esophagus
b) Stomach
c) Jejunum
d) Appendix
Ans: d
Explanation:
Incidence rates for carcinoid tumors have changed; the most common gastrointestinal site is not the appendix, but the small intestine often in terminal ileum, followed in frequency by the rectum, the colon, the appendix, and the stomach.
Most common site for Carcinoid tumor in body- Small intestine
Most common site for Carcinoid tumor in GI Tract- Terminal ileum
Q-8 Which one of the following is not a prion associated disease?
a) Kuru
b) Scrapie
c) Alzheimer’s disease
d) C J disease
Ans: c
Explanation:
Prion associated disease:
The prion diseases are a large group of related neurodegenerative conditions, which affect both animals and humans Included are Creutzfeldt-Jakob disease (CJD), Kuru and Gerstmann-Sträussler-Scheinker (GSS) in humans, bovine spongiform encephalopathy (BSE, or “mad cow disease”) in cattle, chronic wasting disease (CWD) in mule deer and elk, and Scrapie in sheep.
Q-9. The most common side effect of chemotherapy administration is-
a) Nausea
b) Alopecia
c) Myelo-suppression
d) Renal distinction
Answer: Nausea
Explanation:
One of the most commonly known side effects of chemotherapy is nausea and vomiting.
Other common side effects:
Fatigue- Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue.
Hair Loss
Infection
Anemia
Secondary neoplasm
Infertility
Terato-genicity
Peripheral neuropathy
Cognitive impairment
Tumor lysis syndrome
Q-10. Henoch Schonlein Purpura is characterized by the deposition of following immunoglobulin around the vessels
a) IgM
b) IgG
c) IgA
d) IgE
Answer: IgA
Explanation:
Henoch-Schonlein purpura (HSP) is an acute immunoglobulin A (IgA)–mediated disorder characterized by a generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the lungs and the central nervous system (CNS).
Direct immuno-fluorescence (DIF): Immuno-fluorescence studies reveal peri-vascular IgA deposition in almost all patients:
This finding is rare in infantile HSP, in which C3 and IgM are most commonly found in the affected vessel walls.
Renal histology: In most patients, IgA deposits in the mesangium.
Q-11. A 30 year old male resents with numbness of both lower limbs and right upper limb. Examination reveals pulse 88/ minute and B P – 160/110 mm of Hg. He also has digital gangrene involving right 2nd and 3rd finger, urine routine examination is unremarkable. Microscopic examination shows RBC’s Hemogram and serum biochemistry is within normal limits. What is the most probable diagnosis?
a) Systemic lupus erythematosus
b) Polyarteritis nodosa
c) Malignant Hypertension
d) Chrug-Strauss syndrome
Answer: Polyarteritis nodosa
Explanation:
Classic poly-arteritis nodosa is a systemic vasculitis characterized by necrotizing inflammatory lesions that affect medium-sized and small muscular arteries.
Neurologic symptoms:
Sensory and/or motor neuropathies- usually asymmetrical
Mono-neuritis multiplex: This is the successive ischemia or infarction of “named nerves” (e.g., ulnar, radial, peroneal, sural).
Although nerve involvement is initially asymmetrical, the development of additional nerve lesions can cause the clinical picture to resemble symmetrical poly-neuropathy.
CNS involvement – Although rare (≤10% of cases), encephalopathy, focal deficits, strokes, seizures, and, sometimes, brain hemorrhages can occur.
Cutaneous symptoms:
Livedo reticularis
Ulcerations – Especially on the lower extremities, near the malleoli and on the calf
Digital ischemia
Nodules – Usually on the lower extremities
Gastrointestinal symptoms:
Tender abdomen with or without rigidity, guarding, or diminished bowel sounds
GI bleeding
Bowel infarction
Cholecystitis
Renal symptoms:
Hypertension
Costophrenic tenderness
Retroperitoneal or intra-peritoneal hemorrhage
Renal failure
Cardiac symptoms:
Hypertension
Tachycardia out of proportion to fever
Pericardial friction rub
Arrhythmias
Congestive heart failure
Ophthalmologic symptoms:
Retinal vasculitis
Retinal detachment
Cotton-wool spots
Q-12. Ham’s test is useful for the detection of
a) Mannose binding protein
b) Spectrin defect
c) PNH
d) GPI anchor protein
Answer: PNH
Explanation:
The Ham test is a test used in the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH).
Ham’s test relies on the principle that complements attach to RBCs at a moderately acidic pH.
Positive test result shows lysis of Red cells in acidified serum samples with patient’s cell (not with normal cells).
Q-13. Most common site of intracranial hemorrhage in hypertensive hemorrhage is:
a) Basal ganglia
b) Brainstem
c) Cerebellum
d) Hippocampus
Answer: Basal ganglia
Explanation:
Hypertensive intra-cerebral hemorrhages are common. In fact hypertension is the most common cause of intra-cerebral hemorrhages. They can be conveniently divided according to their typical locations which include, in order of frequency:
Basal ganglia hemorrhage (especially the putamen)
Thalamic hemorrhage
Pontine hemorrhage
Cerebellar hemorrhage
Q-14. VHL (Von Hippel Lindau) syndrome includes all except:
a) Endolymphatic sac tumors
b) Pheochromocytoma
c) Hemangioendotheliomas
d) Islet cell tumors
Answer: Hemangioendotheliomas
Explanation:
Von Hippel–Lindau (VHL) disease is a rare, autosomal dominant genetic condition that predisposes individuals to benign and malignant tumors.
The most common tumors found in VHL are central nervous system and retinal hemangioblastomas, clear cell renal carcinomas, pheochromocytomas, pancreatic neuro-endocrine tumors, pancreatic cysts, endo-lymphatic sac tumors and epididymal papillary cystadenomas.
VHL results from a mutation in the von Hippel–Lindau tumor suppressor gene on chromosome 3p25.3.
Q-15. Post transplant lymphoma is
a) T cell
b) B cell
c) Null cell
d) NK cell
Answer: B cell
Explanation:
Post-transplant lymphoproliferative disease (PTLD) is a well-recognized complication of both solid organ transplantation (SOT) and allogeneic hematopoietic stem cell transplantation (HSCT).
It is one of the most common post-transplant malignancies.
In most cases, PTLD is associated with Epstein-Barr virus (EBV) infection of B cells, either as a consequence of reactivation of the virus post-transplantation or from primary EBV infection.
While T-cell lymphoproliferative disorders that are not typically associated with EBV infection also occur after SOT and HSCT, the vast majority are B-cell proliferations.
Q-16. Antibody found in myositis is
a) Anti jo-1
b) Anti scl 70
c) Anti Sm
d) Anti Ku
Answer: Anti jo-1
Explanation:
Myositis-specific auto-antibodies (MSAs):
Aminoacyl-tRNA synthetases (ARSs) are the enzymes that catalyze the binding of amino acids to their corresponding t-RNAs.
Six different auto-antibodies reacting with different ARSs have been identified so far: anti-Jo-1, anti-PL-7, anti-PL-12, anti-EJ, anti-OJ and anti-KS in myositis.
With a few exceptions, each patient has only one of these auto-antibodies.
Patients with anti-SRP (Anti-signal Recognition Particle Antibody) antibody show severe myositis: severe muscle weakness resulting in marked disability, dysphagia and highly elevated levels of serum creatine kinase, with relatively acute onset.
Other auto-antibodies- Anti-Mi-2, Anti-CADM-140, Anti-p155
Q-17. Beevor sign is seen in
a) Abdominal muscle
b) Respiratory muscle
c) Facial muscle
d) Hand muscle
Answer: Abdominal muscle
Explanation:
Beevor’s sign is medical sign seen in the selective weakness of the lower abdominal muscles, involving the movement of the umbilicus towards the head on flexing the neck.
Beevor’s sign is characteristic of spinal cord injury between T10 and T12 levels.
This occurs when the upper part of the Rectus abdominis muscle is intact but the lower part is weak because of the spinal injury.
The sign has also been observed in amyotrophic lateral sclerosis and in facioscapulohumeral muscular dystrophy.
Q-18. Hyperkalemia without ECG changes treated with all except:-
a) Calcium gluconate
b) Resins
c) Na bicarbonate
d) Insulin with dextrose
Answer: Calcium gluconate
Explanation:
In the presence of hypotension or marked QRS widening, intravenous bicarbonate, calcium, and insulin given together with dextrose may be given.
Calcium usually is not indicated in hyper-kalemia without ECG changes or only peaked T waves.
Avoid calcium if digoxin toxicity is suspected. Magnesium sulfate (2 g over 5 min) may be used alternatively in the face of digoxin-toxic cardiac arrhythmias.
Q-19. All of the following are used in the treatment of Hyperkalemia except-
a) Calcium gluconate
b) NAHCO3
c) 50 ml of 50% dextrose
d) Salbutamol
Answer: 50 ml of 50% dextrose
Explanation:
Calcium increases threshold potential, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyper-kalemia.
Glucose and insulin temporarily shift K+ into cells. Administration of hypertonic dextrose alone is not recommended.
Bicarbonate ion neutralizes hydrogen ions and raises urinary and blood pH.
Adrenergic agonist increases plasma insulin concentration, which may in turn help shift K+ into intracellular space.
Q-20. A girl presented with severe hyper-kalemia and peaked T waves on ECG. Fastest way of shifting potassium intra-cellularly is
a) Calcium gluconate IV
b) Oral resins
c) Insulin + glucose
d) Sodium bicarbonate
Answer: Insulin + glucose
Explanation:
Calcium gluconate:
Calcium increases threshold potential, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyper-kalemia.
Calcium usually is not indicated in hyper-kalemia without ECG changes or only peaked T waves.
Avoid calcium if digoxin toxicity is suspected. Magnesium sulfate (2 g over 5 min) may be used alternatively in the face of digoxin-toxic cardiac arrhythmias.
Glucose and insulin:
Glucose and insulin temporarily shift K+ into cells.
Glucose and insulin is the fasted way to lower serum potassium.
Administration of hypertonic dextrose alone is not recommended.
Sodium bicarbonate:
Bicarbonate ion neutralizes hydrogen ions and raises urinary and blood pH.
Adrenergic agonist:
Adrenergic agonist increases plasma insulin concentration, which may in turn help shift K+ into intracellular space.
In the presence of hypotension or marked QRS widening, intravenous bicarbonate, calcium, and insulin given together with dextrose may be given.