Q-161. Which type diabetes is HLA associated
a) Type I diabetes
b) Type II diabetes
c) Malnutrition related type disease
d) Pregnancy related type diabetes
Answer: Type I diabetes
Explanation:
Most of patients with Type 1 DM possess either HLA-DR3 or HLA-DR4.
HLA-DQ genes are even more specific markers for type 1 susceptibility.
Q-162. All of the following are sexually transmitted except
a) Candida albicans
b) Echinococcus
c) Molluscum contagiosum
d) Group B streptococcus
Answer: Echinococcus
Explanation:
Echinococcosis occurs when humans are intermediate hosts for canine tapeworm.
Infection is acquired by ingesting food contaminated with canine feces containing parasite eggs.
After human ingest parasite eggs, the eggs hatch in the intestine to form oncospheres, which penetrate the mucosa, enter the circulation and encyst in specific organs as hydatid cysts.
E. granulosus forms the cysts most commonly in the liver (65 %) and lungs (25 %), but cyst may develop in any organs.
Q-163. All of the following infections may be transmitted via blood transfusion except
a) Parvo B-19
b) Dengue virus
c) Cytomegalovirus
d) Hepatitis G virus
Answer: Dengue virus
Explanation:
Blood transfusion associated viruses:
HVN
HGV
HBV
HIV I
HTLV I
CMV
Parvo Virus B-19
Q-164. Hypoglycemia is a recognized feature of all of the following conditions except
a) Uremia
b) Acromegaly
c) Addison’s disease
d) Hepato-cellular failure
Answer: Acromegaly
Explanation:
Causes of Hypoglycemia:
Hypothermia
Hormones deficiency:
Hypopituitarism
Adrenal insufficiency
Catecholamine deficiency
Glucagon deficiency
Enzyme defect:
Glucose 6 phosphatase
Liver diseases:
Hepatic congestion
Severe hepatitis
Cirrhosis
Important points:
Acromegaly is associated with hyperglycemia.
Fasting hypoglycemia is most commonly due to an adenoma of the islets of Langerhans. Ninety percent such tumors are single and benign. Multiple adenomas have been found in conjunction with MEN Type I.
Whipple triad: It includes hypoglycemic symptoms, fasting blood glucose of 45 mg/dl or less and immediate recovery upon administration of glucose.
Q-165. All of the following feature may be seen in thrombotic thrombocytopenic purpura except
a) Fever
b) Hemolysis
c) Hypertension
d) Low platelets count
Answer: Hypertension
Explanation:
Clinical features of thrombotic thrombocytopenic purpura:
Micro-angiopathic hemolytic anemia
Thrombocytopenia
Fever
Neurological defect
Renal insufficiency- Mild or absent
Decreased activity of ADAMTS-13
Normal routine coagulation studies
Q-166. The following laboratory determinants is abnormally prolonged in ITP
a) APTT
b) Prothrombin time
c) Bleeding time
d) Clotting time
Answer: Bleeding time
Explanation:
Parameter of Thrombocytopenia:
Bleeding time
Parameters of Coagulation disorders:
Clotting time
Prothrombin time
APTT
Q-167. PNH is associated with all of the following condition except
a) Aplastic anemia
b) Increased LAP scores
c) Venous thrombosis
d) Iron deficiency anemia
Answer: Increased LAP scores
Explanation:
Leukocyte alkaline phosphatase (LAP):
An obsolete test and measured as the LAP score
Low LAP score: CML and paroxysmal nocturnal hemoglobinuria (PNH)
Paroxysmal nocturnal hemoglobinuria (PNH):
It is hematopoietic stem cell disorder and may progress to Aplastic anemia or myelo-dysplasia or AML.
Hemolytic anemia
Venous thrombosis especially mesenteric and hepatic vein
Hyper-coagulability due to complement activation
Laboratory findings of PNH:
Iron deficiency anemia due to chronic iron loss
Elevated serum LDH
TLC and platelets may be decreased
Best screening test is flow cytometry to demonstrate deficiency of CD59 and CD55 on RBCs.
Q-168. A 20 year adult presents with severe hypo-plastic anemia. What is most effective treatment?
a) Alpha-interferon
b) IL-2
c) ATG therapy
d) Bone marrow transplant
Answer: Bone marrow transplant
Explanation:
Aplastic anemia:
Hallmark of Aplastic anemia is pancytopenia.
Bone marrow aspirates- Hypo-cellular with normal hematopoietic progenitors
Treatment of mild cases:
Antibiotics and RBC and platelets transfusion
Treatment of severe cases:
Hematopoietic stem cell transplantation or bone marrow transplantation
Criteria of severe Aplastic anemia:
Neutrophil count < 500/mcL Platelets < 20,000/mcL Reticulocyte < 1 % Bone Marrow Cellularity < 20 % Q-169. Which of the following is not commonly seen in polycythemia Vera? a) Thrombosis b) Hyper-uricemia c) Prone for acute leukemia d) Spontaneous severe manifestations Answer: Spontaneous severe manifestations Explanation: Polycythemia Vera: An acquired myelo-proliferative disorder that causes overproduction of all three hematopoietic cell line (RBC, WBC and platelets) Generalized pruritis after warm shower related to histamine release from basophils. Splenomegaly Thrombosis (Most common complication) Peptic ulcer disease Low erythropoietin level Elevated B12 because of increased level of trans-cobalamin III secreted by WBCs Hyper-uricemia Absence iron store in bone marrow Important point: The diagnosis should be confirmed with finding of the JAK2 mutation.
Q-171. The following condition is not associated with an Anti-phospholipid syndrome:
a) Venous thrombosis
b) Recurrent fetal loss
c) Thrombocytosis
d) Neurological manifestations
Answer: Thrombocytosis
Explanation:
Anti-phospholipid antibody syndrome:
Hyper-coagulability with venous or arterial thrombosis
Recurrent fetal loss
Thrombocytopenia
Neurological manifestations
Livedo reticularis
Important point:
Lifelong anticoagulation with Warfarin is recommended.
Q-172. All of the following phases of the jugular venous pulse and their causes are correctly matched except
a) c wave- Onset of atrial systole
b) a-x descent – Atrial relaxation
c) v-y – Emptying of blood from right atrium into right ventricle
d) y-a ascent- Filling of the right atrium from the vena cava
Answer: c wave- Onset of atrial systole
Explanation:
Jugular venous pressure (JVP) provides an indirect measure of central venous pressure.
The JVP consists of certain waveforms and abnormalities of these can help to diagnose certain conditions.
Waves:
a – Pre-systolic; produced by right atrial contraction
c – Bulging of the tricuspid valve into the right atrium during ventricular systole (iso-volumic phase)
v – Occurs in late systole; increased blood in the right atrium from venous return
Descents:
a-x – A combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole
v-y – The tricuspid valve opens and blood flows into the right ventricle.
y-a ascent- Filling of the right atrium from the vena cava
Q-173. Which of the following is the correct statement regarding findings in JVP
a) Cannon wave: Complete hearth block
b) Slow v-y descent: Tricuspid regurgitation
c) Giant c wave: Tricuspid stenosis
d) Increased JVP with prominent pulsations: SVC obstruction
Answer: Cannon wave: Complete hearth block
Explanation:
Cannon waves are very large ‘a’ waves that occur when the right atrium contracts against a closed tricuspid valve.
They occur irregularly in complete heart block and ventricular tachycardia.
Q-174. While inserting a central venous catheter a patient develops respiratory distress. The most likely cause is
a) Hemothorax
b) Pneumothorax
c) Pleural effusion
d) Hypovolemia
Answer: Pneumothorax
Explanation:
Sites of central venous catheterization
Subclavian vein
Internal jugular vein
Femoral vein
Complications of central venous catheterization:
Pneumothorax (Most common and manifested as sudden respiratory distress)
Hemothorax
Air embolism
Q-175. All of the following are clinical features of myxoma; except
a) Fever
b) Clubbing
c) Hypertension
d) Embolic phenomenon
Answer: Hypertension
Explanation:
Cardiac myxoma:
The most common cardiac tumor
Carney complex: It consists of myxoma, pigmented skin lesions and endocrine neoplasia.
The characteristics include fever, malaise, wt loss, Leukocytosis, emboli, clubbing and increased ESR.
Diastolic sound or tumor plop
The diagnosis is established by Echocardiography or pathological study of embolic material.
Q-176. Renal vein thrombosis is most commonly associated with
a) Diabetic nephropathy
b) Membranous Glomerulopathy
c) Minimal change disease
d) Membrano-proliferative glomerulonephritis
Answer: Membranous Glomerulopathy
Explanation:
Membranous Nephropathy:
Most common cause of primary nephrotic syndrome
Associated with coagulopathy, eg, renal vein thrombosis
An immune mediated disease characterized by spike and dome pattern on kidney biopsy from sub-epithelium deposits.
Secondary Causes of Membranous Nephropathy:
HBV
Endocarditis
Syphlis
Autoimmune diseases
Carcinomas
Drugs- Gold, penicillamine and captopril
Q-177. One of the following is a characteristic of Henoch Schonlein purpura
a) Blood in stool
b) Thrombocytopenia
c) Intracranial hemorrhage
d) Susceptibility to infection
Answer: Blood in stool
Explanation:
Henoch Schonlein purpura:
It is most common systemic vasculitis in children and also occurs in adults.
Clinical features:
Palpable purpura
Abdominal pain
Arthritis
Hematuria
Important points:
Pathological features include leukocytoclastic vasculitis with IgA deposition.
Abdominal pain secondary to vasculitis of intestinal tract is often associated with GI bleeding.
Q-178. Renal osteodystrophy differs from nutritional and genetic forms of Osteomalacia in having
a) Hypocalcaemia
b) Hyper-calcemia
c) Hypo-phosphatemia
d) Hyper-phosphatemia
Answer: Hyper-phosphatemia
Explanation:
Renal osteodystrophy:
In end-stage renal disease, renal 1-hydroxylase is diminished or lost, and excretion of phosphate is defective.
This leads to low levels of 1, 25 (OH) 2 vitamin D, hypo-calcemia, hyper-phosphatemia and failure of osteoid calcification.
Important points:
In Osteomalacia, there is hypo-phosphatemia.
Q-179. Medullary cystic disease of the kidney is best diagnosed by
a) Ultrasound
b) Nuclear scan
c) Urography
d) Biopsy
Answer: Biopsy
Explanation:
Medullary cystic disease of the kidney or medullary spongy kidney:
Benign disorder present at birth and not usually diagnosed until the fourth or fifth decade
It is caused by autosomal dominant mutation in the MCKD1 or MCKD2 genes on chromosome 1 and 16 respectively.
It is associated with medullary cysts that are diffuse giving a “Swiss cheese” appearance in this region.
The diagnosis can be made by CT which shows cystic dilatation of the distal collecting tubules, a striated appearance in this area and calcification in renal collecting system.
Open renal biopsy is definitive.
Q-180. A patient with nephrotic syndrome on longstanding cortico-steroid therapy may develop all the following except
a) Hyperglycemia
b) Hypertrophy of muscle
c) Neuropsychiatric symptoms
d) Suppression of the pituitary adrenal axis
Answer: Hypertrophy of muscle
Explanation:
Side effects of corticosteroid:
Hyperglycemia
Atrophy muscle and muscular weakness
Neuropsychiatric symptoms
Suppression of the Hypothalamo-pituitary-adrenal axis
Cushing’s disease
Peptic ulceration
Post sub-scapular cataract/ Glaucoma
Osteoporosis
Delayed wound healing
Growth retardation
Susceptibility to infection
Q-181. Normal anion gap metabolic acidosis is caused by
a) Cholera
b) Starvation
c) Ethylene glycol therapy
d) Lactic acidosis
Answer: Cholera
Explanation:
Metabolic acidosis:
Normal anion gap:
Diarrhoea/ Fistula
Renal tubular acidosis
Ingestion of ammonium chloride
Increased anion gap:
Lactic acidosis- Shock, cardiopulmonary arrest, severe anemia, CO and CN- poisoning
Keto-acidosis- Diabetic, alcoholic and starvation
Exogenous substances- Methanol, salicylates, ethylene glycol (Used as anti-freeze)
Q-182. Causes of metabolic alkalosis include all the following except
a) Mineralocorticoid deficiency
b) Bartter’s syndrome
c) Thiazide diuretic therapy
d) Recurrent vomiting
Answer: Mineralocorticoid deficiency
Explanation:
Metabolic alkalosis: Saline responsive
Normal body bicarbonate content:
Contraction alkalosis
Excessive body bicarbonate content:
A. Renal alkalosis:
Diuretics
Carbenicillin
Penicillin, sulfate and phosphate
Post-hypercapnia
B. GI alkalosis:
Antacids, sodium citrate, lactate, acetate, gluconate and NaHCO3 (Baking soda)
Transfusion
Chloride diarrhoea
Loss of HCL from vomiting or nasogastric suction
Metabolic alkalosis: Saline Un-responsive
Excessive body bicarbonate content:
Renal alkalosis: Normotensive
Batter syndrome
Severe potassium depletion
Re-feeding alkalosis
Hyper-calcemia and hypo-parathyroidism
Hypertensive:
A. Exogenous alkali
B. Licorice
C. Exogenous mineralocorticoids
D. Endogenous mineralocorticoids:
Primary aldosteronism
Hyper-reninism
Liddle syndrome
Adrenal enzyme deficiency- 11 and 17 hydroxylase
Q-183. A 50 kg man with severe metabolic acidosis has the following parameters pH 7.05, pCO2 12mm Hg, pO2 108 mm Hg, HCO3 5mEq/L and base excess 30 mEq/ L. The approximate quantity of sodium bicarbonate that he should receive in half hour is?
a) 250 mEq
b) 350 mEq
c) 500 mEq
d) 750 mEq
Answer: 250 mEq
Explanation:
The hallmark of metabolic acidosis is decreased HCO3.
The bicarbonate deficiency can be calculated as follows:
HCO3- deficit = 0.5 x body wt in kg x (24- HCO3-)
Half of the calculated deficit should be administered the first three to four hours to avoid overcorrection and volume overload.
Q-184. Most sensitive and specific test for diagnosis of iron deficiency is
a) Serum iron levels
b) Serum ferritin levels
c) Serum transferrin receptor population
d) Transferrin saturation
Answer: Serum ferritin levels
Explanation:
Iron deficiency develops in stages. The first is depletion of iron stores.
At this point, there is anemia and no changes in RBS size.
A ferritin value < 12 mcg/L is a highly reliable indicator of depletion of iron stores. Q-185. Leuko-erythroblastic picture may be seen in all of the following except a) Myelo-fibrosis b) Metastatic carcinoma c) Gaucher’s disease d) Thalassemia Answer: Thalassemia Explanation: Leuko-erythroblastic picture: The leuko-erythroblastic picture is characterized by nucleated red blood cells and teardrop forms, giant platelets, and immature white blood cells in the peripheral blood smear. It is usually accompanied by fibrosis of the bone marrow and may be seen in A. Primary Myelo-fibrosis B. Secondary Myelo-fibrosis Infection- Tuberculosis, fungal and HIV Lipid deposition- Gaucher’s disease Tumors- Metastatic carcinoma, Lymphoma, Multiple myeloma, Leukemia and Polycythemia Vera Q-186. All of the following are poor prognostic factor for acute myeloid leukemias except a) Age more than 60 years b) Leucocytes count more than 100000/μl c) Secondary leukemias d) Presence of t (8:21) Answer: Presence of t (8:21) Explanation: Poor prognostic factor for acute myeloid leukemias: Age more than 60 years Leucocytes count more than 100, 000/μl Secondary leukemias Monosomy 7 Good prognostic factor for acute myeloid leukemias: Age less than 60 years Presence of t (8:21) Leucocytes count less than 100000/μl Q-187. A 63 year old man presented with massive splenomegaly, lymphadenopathy and a total leukocyte count of 17000 per mm³. The following cytometry showed CD19 positive, CD5 positive, CD23 negative, monoclonal B-cells with bright kappa positively comprising 80% of the peripheral blood lymphoid cells. The most likely diagnosis is a) Mantle cell lymphoma b) Splenic lymphoma with villous lymphocytes c) Follicular lymphoma d) Hairy cell leukemia Answer: Mantle cell lymphoma Explanation: Q-188. All of the following statement regarding the ECG in acute pericarditis are true except a) T wave inversions develop before ST elevation return to baseline b) Global ST segment elevation is seen in early pericarditis c) Sinus tachycardia is a common finding PR segment depression is present in majority of patients d) None Answer: T wave inversions develop before ST elevation return to baseline Explanation: ECG in acute pericarditis: A characteristic progression beginning with diffuse ST elevation, followed by a return to baseline and then to T wave inversion Atrial injury is often present and manifested by PR depression especially in the limb leads. Q-189. All of the following are the electrocardiographic features of severe hyper-kalemia except a) Peaked T waves b) Presence of U waves c) Sine waves pattern d) Loss of P waves Answer: Presence of U waves Explanation: Electrocardiographic features of hyper-kalemia: PR interval prolongation Peaked T wave QRS widening Merger of QRS complex and T wave leads to the appearance of a typical sine-wave pattern Biphasic QRS-T complex Electrocardiographic features of Hypokalemia: Decreased amplitude and broadening of T wave Prominent U wave Depressed ST segment Important point: Hyperkalemia impairs neuromuscular transmission causing weakness, flaccid paralysis and ileus. Q-190. Hypo-calcemia is characterized by all of the following features except a) Numbness and tingling of circum-oral region b) Hyperactivity tendon reflexes c) Shortening of Q-T interval in ECG d) Carpo-pedal spasm Answer: Shortening of Q-T interval in ECG Explanation: Hypo-calcemia: Symptoms and signs: Spasm of skeletal muscle causes cramps and tetany Larygospasm with stridor Abdominal pain Convulsion, peri-oral and peripheral paresthesia Chvostek’s Sign- Contraction of facial muscle in response to tapping the facial nerve Trousseau sign- Carpal spasm with occlusion of the brachial artery by blood pressure cuff Laboratory findings: Serum calcium < 8.5 mg/dl Ionized serum calcium < 4.5 mg/dl Low magnesium concentration ECG- Prolonged QT interval Q-191. Which of the following is the most common location of the hypertensive hemorrhage? a) Pons b) Thalamus c) Sub-cortical white matter d) Putamen/ external capsule Answer: Putamen/ external capsule Explanation: 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-192. Absence seizures are characterized on EEG by a) 3 Hz spike & wave b) 1-2 Hz spike & wave c) Generalized poly-spikes d) None of above Answer: 3 Hz spike & wave Explanation: Absence seizures are characterized by impairment of consciousness, sometimes with mild clonic, tonic or atonic components, autonomic components (Enuresis) or accompanying automatisms. EEG: Burst of bilaterally synchronous and symmetrical 3 Hz spike and wave activity. Q-193. Commonest presentation of neuro-cysticercosis is a) Seizures b) Focal neurological deficits c) Dementia d) Radiculopathy Answer: Seizures Explanation: Epilepsy is the most common presentation of neuro-cysticercosis and is also a complication of the disease. Neuro-cysticercosis is the leading cause of adult-onset epilepsy and is probably one of the most frequent causes of childhood epilepsy. Q-194. Commonest cause of sporadic encephalitis is a) Japanese B virus b) Herpes simplex virus c) Human immunodeficiency virus d) Rubeola virus Answer: Herpes simplex virus Explanation: Herpes simplex virus type-1 (HSV-1) encephalitis is the most common cause of sporadic fatal encephalitis worldwide. The clinical syndrome is often characterized by the rapid onset of fever, headache, seizures, focal neurologic signs, and impaired consciousness. Q-195. Serum total lactate dehydrogenase level will NOT be raised in a) Muscle Crush Injury b) Stroke c) Myocardial Infarction d) Hemolysis Answer: Stroke Explanation: LDH enzyme is widely distributed but especially plentiful in cardiac and skeletal muscle, liver, kidney and RBC. Q-196. Thiamine deficiency is known to occur in all of the following except a) Food faddist b) Homocystinemia c) Chronic alcoholic d) Chronic heart failure patient on diuretics Answer: Homocystinemia Explanation: Causes of thiamine deficiency: Malnutrition Dietary habits Alcoholics Food faddist Chronic heart failure Diuretics- induce increased excretion of thiamine in urine Q-197. A 30 year old HIV positive patient presents with fever, dyspnea and non- productive cough. Patient is cyanosed. His chest X-ray reveals bilateral symmetrical interstitial infiltrates. The most likely diagnosis is a) Tuberculosis b) Cryptococcosis c) Pneumocystis carinii pneumonia d) Toxoplasmosis Answer: Pneumocystis carinii pneumonia Explanation: Pneumocystis carinii pneumonia (PCP) is caused by P carinii. It is a frequent cause of morbidity and mortality in persons who are immuno-compromised, especially patients with acquired immunodeficiency syndrome (AIDS). X-Ray Chest Finding: Bilateral diffuse infiltrate beginning peri-hilar region Q-198. A 60 year old man with diabetes mellitus present with painless swollen right ankle joint. Radiographs of the ankle show destroyed joint with large number of loose bodies. The most probable diagnosis is a) Charcot’s joint b) Clutton’s joint c) Osteoarthritis d) Rheumatoid arthritis Answer: Charcot’s joint Explanation: Charcot joint or neuropathic joint (Pain less) is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. This disorder results in progressive destruction of bone and soft tissues at weight-bearing joints. Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and ankle. Charcot arthropathy occurs as a complication of diabetes, syphilis, chronic alcoholism, leprosy, meningomyelocele, spinal cord injury and syringomyelia. Diabetes is considered to be the most common cause of Charcot arthropathy. Q-199. Central nervous system manifestation in chronic renal failure are a result of all of the following except a) Hyper-osmolarity b) Hypo-calcemia c) Acidosis d) Hypo-natremia Answer: Hypo-calcemia Explanation: Patient with chronic renal disease tolerate the hypo-calcemia quite well and rarely is a patient symptomatic from the decreased calcium concentration. Q-200. A 25 year old man presented with fever, cough, expectoration and breathlessness of 2 months duration. Contrast enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinum had enlarged necrotic nodes with peripheral rim enhancement which one of the following is the most probable diagnosis a) Sarcoidosis b) Tuberculosis c) Lymphoma d) Silicosis Answer: Tuberculosis Explanation: Contrast enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinum had enlarged necrotic nodes with peripheral rim enhancement- A possibility of tuberculosis
Q-201. Cardiac output measured by thermo-dilution technique is unreliable in all of the following situations except
a) Ventricular septal defect
b) Tricuspid regurgitation
c) Low cardiac output
d) Pulmonary regurgitation
Answer: None
Explanation:
Cardiac output measured by thermo-dilution technique is unreliable in:
Pulmonary valve insufficiency
Tricuspid regurgitation
Low cardiac output status
Right to left shunt
Left to right shunt
Q-202. All of the following heart sounds occur shortly after S2 except
a) Opening snap
b) Pericardial knock
c) Ejection click
d) Tumor plop
Answer: Ejection click
Explanation:
Heart sounds occur shortly after S1:
Ejection click
Heart sounds occur shortly after S2:
Opening snap
Pericardial knock
Tumor plop
Third heart sound
Shortly before S1:
Fourth heart sound
Between S1 and S2:
Mid-systolic click
Q-203. An early systolic murmur may be caused by all of the following except
a) Small ventricular septal defect
b) Papillary muscle dysfunction
c) Tricuspid regurgitation
d) Aortic stenosis
Answer: Aortic stenosis
Explanation:
Systolic Murmurs:
Early Systolic murmurs:
VSD- Large VSD with pulmonary hypertension and small VSD
Tricuspid regurgitation in absence of pulmonary hypertension
Mitral regurgitation in non-compliant left atrium
Mid systolic murmur:
Aortic- Aortic stenosis, Coarctation, Aneurysm, PDA and High output states
Pulmonary- Pulmonary stenosis, pulmonary hypertension, pulmonary artery dilatation, ASD and High output states
Pansystolic or Holosystolic murmur:
VSD
Tricuspid regurgitation
Mitral regurgitation
Aortico-pulmonary shunt
Important point:
Conditions producing acute mitral regurgitation- Rupture of chordae tendinae, papillary muscle dysfunction and infective endocarditis
Q-204. Exercise testing is absolutely contraindicated in which one of the following
a) One week following myocardial infarction
b) Unstable angina
c) Aortic stenosis
d) Peripheral vascular disease
Answer: Aortic stenosis
Explanation:
Contra-indications of exercise stress testing:
Acute MI (< 4-5 days) Rest angina (< 48 hours) Acute myocarditis Severe aortic stenosis Active infective endocarditis Un-controlled heart failure Unstable rhythm Q-205. The most common cause of tricuspid regurgitations is secondary to a) Rheumatoid heart disease b) Dilatation of right ventricle c) Coronary artery disease d) Endocarditis due to intravenous drug abuse Answer: Dilatation of right ventricle Explanation: Most common cause of TR is functional and secondary to marked dilatation of right ventricle and tricuspid annulus. Q-206. Which of the heart valve is most likely to be involved by infective endocarditis following a septic abortion? a) Aortic Valve b) Tricuspid valve c) Pulmonary valve d) Mitral valve Answer: Tricuspid valve Explanation: Infective endocarditis involving right heart valves: Intravenous drug abusers Septic abortion Staphylococcus aureus may cause right-sided endocarditis with large vegetation and it may follow septic abortion. Q-207. Osler’s nodes are typically seen in which one of the following? a) Chronic Candida endocarditis b) Acute staphylococcal endocarditis c) Pseudomonas endocarditis d) Libman sack’s endocarditis Answer: Acute staphylococcal endocarditis Explanation: Peripheral signs of endocarditis: Roth’s spots: Oval- shaped, white- centered hemorrhages present on the retina Osler’s nodes: Painful, erythematous nodules most commonly found on the pads of the fingers and toes Janeway lesions: Non-tender, erythematous and nodular lesions most commonly found on the palms and soles Splinter hemorrhages: Small, linear hemorrhages under the nails Important point: Staphylococcus aureus is leading cause of infective endocarditis; and gram negative organism and fungi account for small percentage. Q-208. Troponin-T is preferable to CPK-MB in the diagnosis of acute myocardial infarction (MI) in all of the following situations except a) Bedside diagnosis of MI b) Postoperatively (after CABG) c) Re-infarction after 4 days d) Small infarcts Answer: Re-infarction after 4 days Explanation: Troponin is more sensitive and specific than CK-MB. Circulating levels of Troponin may remain elevated for 5-7 days or longer and therefore are generally not useful for evaluating suspected early re-infarction. Elevated CK-MB generally normalizes within 24 hours, thus being more helpful for evaluation of re-infarction. Q-209. During cardiopulmonary resuscitation, intravenous calcium gluconate is indicated under all of the following circumstances except a) After 1 minute of arrest routinely b) Hypo-calcemia c) Calcium channel blockers toxicity d) Electromechanical dissociation Answer: After 1 minute of arrest routinely Explanation: Indications of intravenous calcium gluconate administration during cardiopulmonary resuscitation: Known hypo-calcemia Toxic dose of calcium channel blockers Acute hypokalemia triggering event for resistant ventricular fibrillation (?) Electromechanical dissociation Q-210. A post-operative cardiac surgical patient developed sudden hypotension; raised central venous pressure and Pulsus paradoxus at the 4th post operative hour. The most probable diagnosis is a) Excessive mediastinal bleeding b) Ventricular dysfunction c) Congestive cardiac failure d) Cardiac tamponade Answer: Cardiac tamponade Explanation: Acute cardiac tamponade: Elevated intra-pericardial pressure > 15 mm Hg
Signs and symptoms:
Pain in inflammatory cases or painless in neoplastic or uremic effusion
Dyspnea and cough
A pericardial friction rub
Tachycardia and tachypnea
Pulsus paradoxus (Also found in obstructive lung disease and asthma) and a relatively preserved systolic pressure
Elevated central venous pressure
Investigation:
Echocardiography is primary method for demonstrating pericardial effusion.
ECG: Non-specific T wave changes and low QRS voltage X-ray chest: Enlarged cardiac silhouette with globular configuration
Treatment:
Urgent paracentesis when tamponade present
Q-211. The blood gas parameters pH 7.58, pCO2 23 mm Hg, pO2 300 mmHg and oxygen saturation 60 % are most consistent with
a) Carbon monoxide poisoning
b) Ventilatory malfunction
c) Voluntary malfunction
d) Methyl alcohol poisoning
Answer: Ventilatory malfunction (?)
Explanation:
Carbon monoxide poisoning- Acidic pH
Methyl alcohol poisoning- Acidic pH
Q-212. The diffusion capacity of lung (DLCO) is decrease in all of the following conditions except
a) Interstitial lung disease
b) Goodpasture’s syndrome
c) Emphysema
d) Primary pulmonary hypertension
Answer: Goodpasture’s syndrome
Explanation:
This test is used to estimate the transfer of oxygen from the alveoli in lungs to bloodstream.
The diffusing capacity (DL) of oxygen is technically very difficult to measure, and the test actually measures the diffusing capacity of carbon monoxide (DLCO) which provides a valid estimate of the oxygen diffusion.
Lowered the diffusion capacity of lung:
Interstitial lung disease
Emphysema
Pulmonary hypertension/ pulmonary emboli
Elevated the diffusion capacity of lung:
Goodpasture’s syndrome
Q-213. A 55 year old man who has been on bed rest for the past 10 days complains of breathlessness and chest pain. The chest X-ray is normal. The next investigation should be
a) Lung Ventilation-perfusion Scan
b) Pulmonary Arteriography
c) Pulmonary Venous Angiography
d) Echocardiography
Answer: Lung Ventilation-perfusion Scan
Explanation:
Pulmonary venous thrombo-embolism:
Clinical features:
Dyspnea, chest pain, hemoptysis and syncope
Laboratory findings:
ECG: Sinus tachycardia and non-specific ST and T wave changes
ABG: Respiratory acidosis and the arterial Po2 and the alveolar-arterial oxygen difference usually abnormal
D-dimer: Increased level of plasma D-dimer
Chest X-ray:
May be normal or
Atelectasis, parenchymal infiltration and pleural effusion
Ventilation-perfusion lung Scan
Helical CT pulmonary angiography
Pulmonary angiography-Reference standard for the diagnosis of PE
Q-214. Diagnostic features of allergic bronchopulmonary aspergillosis (ABPA) include all of the following except
a) Changing pulmonary infiltrates
b) Peripheral eosinophilia
c) Serum precipitins against aspergillosis fumigants
d) Occurrence in patients with old cavitatory lesions
Answer: Occurrence in patients with old cavitatory lesions
Explanation:
Primary criteria for diagnosis of allergic bronchopulmonary aspergillosis (ABPA):
A clinical history of asthma
Peripheral eosinophilia
Immediate skin reactivity to Aspergillus antigen
Precipitating antibodies to Aspergillus antigen
Elevated serum IgE levels
Pulmonary infiltrate
Central bronchiectasis
Secondary diagnostic criteria:
Aspergillus in sputum
A history of brown flecked sputum
Late skin reactivity to Aspergillus antigen
Q-215. Which one of the following conditions may lead to exudative pleural effusion?
a) Cirrhosis
b) Nephrotic syndrome
c) Congestive heart failure
d) Bronchogenic carcinoma
Answer: Bronchogenic carcinoma
Explanation:
Causes of pleural effusion:
Transudative pleural effusion:
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Peritoneal dialysis
Myxedema
Constrictive pericarditis
SVC obstruction
Exudative pleural effusion:
Cancer
Pneumonia
Tuberculosis
Connective tissue diseases
Viral infection
Meig’s syndrome
Pancreatic disease
Uremia
Chylothorax
Drug reaction
Post MI syndrome
Q-216. Pulmonary hypertension may occur in all of the following conditions except
a) Toxic oil syndrome
b) Progressive syndrome
c) Sickle cell anemia
d) Argemone Mexicana poisoning
Answer: Argemone Mexicana poisoning
Explanation:
Epidemic dropsy is a clinical state resulting from use of edible oils adulterated with Argemone Mexicana oil. Sanguinarine and dihydro-sanguinarine are two major toxic alkaloids of Argemone oil, which cause widespread capillary dilatation, proliferation and increased capillary permeability.
Leakage of the protein-rich plasma component into the extracellular compartment leads to the formation of edema.
Important point:
Pulmonary hypertension doesn’t occur in Argemone Mexicana poisoning.
Q-217. A 60 year old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is
a) Thymoma
b) Lung cancer
c) Hodgkin’s lymphoma
d) Superior vena caval obstruction
Answer: Superior vena caval obstruction
Explanation:
Superior vena caval obstruction:
Dyspnea, dizziness, headache, visual disturbance or syncope
Bending over or lying down accentuates the symptoms.
Swelling of the neck, face and upper extremities
Dilated veins over upper chest and neck
Q-218. Which of the following hepatitis viruses have significant perinatal transmission?
a) Hepatitis E virus
b) Hepatitis C virus
c) Hepatitis B virus
d) Hepatitis A virus
Answer: Hepatitis B virus
Explanation:
Perinatal transmission in decreasing order:
Hepatitis B virus
Hepatitis D virus
Hepatitis C virus
Q-219. The syndrome of inappropriate anti-diuretic hormone is characterized by the following
a) Hypo-natremia and urine sodium excretion >20 meq/L
b) Hypernatremia and urine sodium excretion >20 meq/L
c) Hypo-natremia and Hyper-kalemia
d) Hypernatremia and Hypokalemia
Answer: Hypo-natremia and urine sodium excretion >20 meq/L
Explanation:
Clinical diagnosis of SIADH:
Hypo-natremia
Urine Na+ > 20 mEq/L
Decreased osmolality
Normal thyroid and adrenal function
Absence of heart, kidney or liver disease
Q-220. A 23- year old woman has experienced episodes of myalgias, pleural effusion, pericarditis and arthralgias without joint deformity over course of several years. The best laboratory screening lest to diagnose her disease would be
a) CD4 lymphocyte count
b) Erythrocyte sedimentation rate
c) Antinuclear antibody
d) Assay for thyroid hormones
Answer: Antinuclear antibody
Explanation:
Laboratory findings of SLE:
Antinuclear antibody test is sensitive but not specific to SLE. They are positive in virtually all patients with SLE.
Antibodies to ds-DNA and Sm are specific for SLE but not sensitive.
Decreased serum complement- A finding suggestive of disease activity and often retunes toward normal in remission.
Q-221. Disseminated intravascular coagulation (DIC) differs from thrombotic thrombocytopenic purpura (TTP). In this reference the DIC is most likely characterized by:
a) Significant numbers of schistocytes
b) A brisk reticulocytosis
c) Decreased coagulation factor levels
d) Significant thrombocytopenia
Answer: Decreased coagulation factor levels
Explanation:
Disseminated intravascular coagulation (DIC) is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to micro-vascular thrombi in various organs and contributing to multiple organs dysfunction syndrome (MODS).
Consumption and subsequent exhaustion of coagulation proteins and platelets (from ongoing activation of coagulation) may induce severe bleeding, though micro-clot formation may occur in the absence of severe clotting factor depletion and bleeding.
In DIC, the levels of coagulation factors are decreased. Whereas in TTP, coagulation factor levels are normal.
Q-222. A 5 year old girl came with history of progressively increasing pallor since birth and hepato-splenomegaly which of the following is the most relevant test for achieving diagnosis
a) Hb electrophoresis
b) Peripheral smear examination
c) Osmotic fragility test
d) Bone marrow examination
Answer: Hb electrophoresis
Explanation:
Hemoglobin electrophoresis is the test of choice for diagnosing thalassemia.
Thalassemia minor:
Clinically insignificant
Microcytic anemia
Thalassemia intermedia:
Progressive and chronic hemolytic anemia
They survive into adult life.
Hepato-splenomegaly and bony deformities
Thalassemia major:
Affected child are normal at birth but after 6 months, when hemoglobin synthesis switches from hemoglobin F to HbA, develop severe anemia requiring transfusion.
Q-223. Elevated serum ferritin, serum iron and percent transferring saturation are most consistent with the diagnosis of
a) Iron deficiency anemia
b) Anemia of chronic disease
c) Hemochromatosis
d) Lead poisoning
Answer: Hemochromatosis
Explanation:
Complications of hemochromatosis:
Arthropathy
Cardiac enlargement, heart failure and conduction defect
Diabetes mellitus
Hypopituitarism, erectile dysfunction
Liver cirrhosis, portal hypertension, hepato-cellular carcinoma
Diagnosis of hemochromatosis:
Elevated plasma iron
More than 50 % transferrin saturation in men and 45 % in women
Elevated serum ferritin
Testing for HFE mutation
Treatment of hemochromatosis:
Avoid foods rich iron, alcohol, vitamin C etc
Weekly phlebotomies
Proton pump inhibitor-Reduces intestinal iron absorption
IV deferoxamine/ Oral deferasirox
Q-224. Bone marrow transplantation can be used as a treatment for all except
a) Osteo-petrosis
b) Adreno-leuko-dystrophy
c) Hurler’s syndrome
d) Hemochromatosis
Answer: Hemochromatosis
Explanation:
Treatment of hemochromatosis:
Avoid foods rich iron, alcohol, vitamin C etc
Weekly phlebotomies
Proton pump inhibitor-Reduces intestinal iron absorption
IV deferoxamine/ Oral deferasirox
Q-225. All of the following statement are true about sickle cell disease except
a) Patient may require frequent blood transfusions
b) Acute infection is the most common cause of mortality before 3 years of age
c) There is positive correlation between concentration of HbS and polymerization of HbS
d) Patient presents early in life before 6 months of age
Answer: Patient presents early in life before 6 months of age
Explanation:
Sickle cell anemia is an autosomal recessive disorder.
The rate of sickling is influenced by the concentration of hemoglobin S.
Hemoglobin F markedly retards sickling.
Sickle cell anemia is confirmed by hemoglobin electrophoresis.
Treatment:
Folic acid
Frequent transfusion
Pneumococcal vaccination
Q-226. All of the following are seen in cardiac tamponade except
a) Pulsus paradoxus
b) Diastolic collapse of right ventricle on echocardiogram
c) Electrical Alternans
d) Kussmaul’s sign
Answer: Kussmaul’s sign
Explanation:
Acute cardiac tamponade:
Elevated intra-pericardial pressure > 15 mm Hg
Signs and symptoms:
Pain in inflammatory cases or painless in neoplastic or uremic effusion
Dyspnea and cough
A pericardial friction rub
Tachycardia and tachypnea
Pulsus paradoxus (Also found in obstructive lung disease and asthma) and a relatively preserved systolic pressure
Elevated central venous pressure
Investigation:
Echocardiography is primary method for demonstrating pericardial effusion.
ECG: Non-specific T wave changes and low QRS voltage X-ray chest: Enlarged cardiac silhouette with globular configuration
Treatment:
Urgent paracentesis when tamponade present
Kussmaul’s sign is the paradoxical rise in jugular venous pressure with inspiration.
Causes of Kussmaul’s sign include right ventricular infarction, severe right ventricular failure, restrictive cardiomyopathy, constrictive pericarditis, and tricuspid stenosis.
Q-227. In hematuria of glomerular origin the urine is characterized be the presence of all of the following except
a) Red cell casts
b) Acanthocytes
c) Crenated red cells
d) Dysmorphic red cells
Answer: Acanthocytes
Explanation:
Hematuria of glomerular origin:
Red cell casts
Crenated red cells
Dysmorphic red cells
Important points:
Acanthocytes or spur cells are spiculated red cells with a few projections of varying size and surface distribution.
Acanthocytosis is a red cell phenotype associated with various underlying conditions. The most frequent and most significant conditions include abetalipoproteinemia and spur cell hemolytic anemia of severe liver disease.
Q-228. Polycystic disease of the kidney may have cysts in all of the following organs except
a) Lung
b) Liver
c) Pancreas
d) Spleen
Answer: Lung
Explanation:
Polycystic disease of the kidney has concurrent:
Hepatic cyst
Pancreatic cyst
Splenic cyst
Ovarian cyst
Q-229. A 40 year old man presented with painless hematuria. Bimanual examination revealed a ballotable mass over the right flank. Subsequently right Nephrectomy was done and mass was seen to be composed of cells with clear cytoplasm. Areas of hemorrhage and necrosis were frequent. Cytogenic analysis of this mass is likely to reveal an abnormality of
a) Chromosome 1
b) Chromosome 3
c) Chromosome 11
d) Chromosome 17
Answer: Chromosome 3
Explanation:
Renal Cell carcinoma
Q-230. Which of the following is the drug of first choice for Non-gonococcal urethritis?
a) Ceftriaxone
b) Ciprofloxacin
c) Doxycycline
d) Minocycline
Answer: Doxycycline
Explanation:
Chlamydia trachomatis is the most common cause of non gonococcal urethritis.
Treatment regimen:
Azithromycin or
Doxycycline or
Levofloxacin