Q-51. Pulsus paradoxus is/are present in all except
a) Hypovolemic shock
b) Pulmonary embolism
c) Right ventricular myocardial infarction
d) Cardiac tamponade
e) Severe COPD
Answer: c
Explanation:
Pulsus paradoxus occurs in:
Cardiac tamponade
Constrictive pericarditis
Hypovolemic shock
Acute and chronic obstructive airways disease
Pulmonary embolus
Q-52. Loud S1 present in
a) MS with pliable valve
b) MS with calcified valve
c) MR
d) AS
e) TR
Answer: a
Explanation:
Normal S1: AS
Soft S1: MS with calcified valve, MR, TR
Loud S1: MS with pliable valve
Q-53. Chloride resistant metabolic alkalosis seen in all except
a) Primary aldosteronism
b) Milk alkali syndrome
c) Vomiting
d) Diuretic use
e) Hypokalemia
Answer: c, d and e
Explanation:
Chloride-Resistant Metabolic Alkalosis:
Primary hyper-aldosteronism
Cushing syndrome
Syndrome of apparent mineralo-corticoid excess
Licorice ingestion
Bartter syndrome and Gitelman syndrome
Liddle syndrome
Milk Alkali Syndrome
Q-54. Which of the following statement (s) is not true about myasthenia gravis?
a) More sensitive to non-depolarizing
b) More sensitive to depolarizing
c) Single-fiber electromyography shows blocking and jitters
d) Proximal muscle involvement
e) Repeated electric stimulation enhance muscle power
Answer: b and e
Explanation:
Myasthenia gravis (MG) is a relatively rare autoimmune disorder in which antibodies form against acetylcholine nicotinic postsynaptic receptors at the neuromuscular junction of skeletal muscles.
These patients are resistant to depolarizing agents and hypersensitive to non-depolarizing agents.
Electro-diagnostic studies:
Repetitive stimulation of a muscle at 2-3 Hz, also known as repetitive nerve stimulation (RNS)
Single-fiber electromyography (SFEMG), aimed at evaluating neuromuscular block, jitter, and fiber density
SFEMG is more sensitive than RNS in assessing MG.
During low-frequency (1-5 Hz) RNS, the locally available acetylcholine (ACh) becomes depleted at all neuromuscular junctions (NMJs), and less is therefore available for immediate release. This results in smaller excitatory postsynaptic potentials (EPSPs).
Q-55. Drugs causing pancreatitis
a) Steroids
b) Isoniazid
c) Paracetamol
d) Aspirin
e) Fexofenadine
Answer: a, b and c
Explanation:
Drugs definitely associated with acute pancreatitis include the following:
Azathioprine
Sulfonamides
Sulindac
Tetracycline
Valproic acid
Didanosine
Methyldopa
Estrogens
Frusemide
6-Mercaptopurine
Pentamidine
5-aminosalicylic acid compounds
Corticosteroids
Octreotide
Q-56. Symptom (s) of acute exacerbation of COPD is/are
a) Fever
b) Increased dyspnea
c) Increased sputum production
d) Change in character of sputum
e) Weight loss
Answer: a, b, c and d
Explanation:
Symptoms of acute exacerbation of COPD:
Increased dyspnea
Increased cough; increased sputum purulence and increased sputum volume
Upper airway symptoms
Increased wheeze and chest tightness
Q-57. Clinical feature of hyper-calcemia in carcinoma include (s)
a) Vomiting
b) Diarrhoea
c) Sinus tachycardia
d) Hypo-reflexia
e) Confusion
Answer: a, d and e
Explanation:
Clinical manifestations of humoral hyper-calcemia in malignancy:
Anorexia Nausea Vomiting Constipation
Fatigue
Depression
Mental confusion
Reversible renal tubular defects and increased urination
A short Q interval and cardiac arrhythmias
Q-58. Pancytopenia with hyper-cellular marrow is not a feature of
a) SLE
b) PNH
c) Sarcoidosis
d) Fanconi anemia
Answer: Fanconi anemia
Explanation:
Thrombocytopenia associated with congenital conditions:
Amegakaryocytic thrombocytopenia
Wiskott Aldrich syndrome
Thrombocytopenia absent radius syndrome (TAR Syndrome)
Thrombocytopenia with depression in other blood cell counts associated with congenital conditions:
Fanconi anemia
Dyskeratosis congenital
Q-59. Poor prognostic factor in acute pancreatitis is
a) Increased serum amylase
b) Increased serum calcium
c) Increased blood sugar
d) Increased PaO2
Answer: Increased blood sugar
Explanation:
Ranson criteria for assessing the severity of acute pancreatitis:
Criteria on admission:
Age: >55 years
White blood count: > 16 000/mm
Blood glucose level: > 200 mg/dl (11.0 mmol/ l)
Lactate dehydrogenase (LDH): > 350 IU/ l
Aspartate amino-transferase (AST): > 250 U/ l
Criteria after 48 hours of admission:
Packed cell volume: decrease >10% from admission
Blood urea nitrogen (BUN): increase > 5 mg/dl (1.8 mmol/l) from admission
Calcium: < 8 mg/dl (0.2 mmol/ l) Oxygen partial pressure: <60 mm Hg Base deficit: >4 mmol/ l
Fluid sequestration: >6 l
Q-60. Diarrhoea may be a feature of all of the following disease states, except
a) Carcinoid syndrome
b) Diabetic autonomic neuropathy
c) Thyrotoxicosis
d) Hyperparathyroidism
Answer: Diabetic autonomic neuropathy (Most correct answer)
Explanation:
Causes of chronic diarrhoea:
Osmotic diarrhoea:
Medications: Antacids, lactulose and sorbitol
Disaccharide deficiency: Lactose intolerance
Factitious diarrhoea: Magnesium (Antacids, laxatives)
Motility disorders:
Postsurgical: Vagotomy, partial gastrectomy, blind loop with bacterial overgrowth
Systemic disorders: Scleroderma, DM, hyperthyroidism
Irritable bowel syndrome
Secretory diarrhoea:
Hormonally mediated: VIPoma, carcinoid, medullary carcinoma of thyroid (Calcitonin), ZE syndrome (Gastrin)
Villous adenoma
Bile salt mal-absorption
Factitious diarrhoea: Laxative abuse
Mal-absorption syndromes:
Small bowel mucosal disorders: Celiac sprue, Tropical sprue, Whipple disease, Crohn’s disease, Small bowel resection, Eosinophilic gastro-enteritis
Lymphatic obstruction: Lymphoma, carcinoid, tuberculosis, Kaposi sarcoma, sarcoidosis and retro-peritoneal fibrosis
Pancreatic diseases
Bacterial overgrowth
Inflammatory conditions:
Ulcerative colitis
Crohn’s disease
Microscopic colitis
Malignancy: Lymphoma and Adenocarcinoma
Radiation enteritis
Important points:
Diabetic autonomic neuropathy causes stasis.
Parathyroid crisis is a rare condition that sometimes occurs when people with hyperparathyroidism experience vomiting or diarrhea, which causes excessive fluid loss.
Q-71. Gastric ulcer is caused by with bacteria
a) E. coli
b) Helicobacter
c) Proteus
d) Entamoeba histolytica
Answer: Helicobacter pylori
Explanation:
Helicobacter pylori:
Helicobacter is a Gram-negative, micro-aerophilic spiral-shaped bacterium found in stomach, causing peptic ulcer disease, gastric cancer or mucosa-associated-lymph-tissue (MALT) lymphoma.
Q-72. Creatinine phospho-kinase is increased in
a) Alcoholic myopathy
b) Clofibrates therapy
c) After electro-cardioversion
d) All
Answer: All
Explanation:
Creatine phospho-kinase (CPK) is an enzyme found mainly in the heart, brain, and skeletal muscle.
High CPK levels may be seen in patients who have:
Brain injury or Stroke, Convulsion
Polymyositis, Muscular dystrophies, Myopathy, Electric shock
Myocarditis, MI, after electro-cardioversion
Important points:
Clofibrates therapy causes myopathy, including rhabdomyolysis with acute renal failure secondary to myoglobinuria.
The myopathy may be dose-related in conjunction with increases in creatine phospho-kinase (CPK). Therapy with fibric acid derivatives should be administered cautiously in patients with preexisting myopathy or a myo-neural disorder.
Q-73. Sensation lost first in Syringomyelia is
a) Pain & temperature
b) Position
c) Touch
d) Vibration
Answer: Pain & temperature
Explanation:
Syringomyelia interrupts the decussating spino-thalamic fibers that mediate pain and temperature sensibility, resulting in loss of these sensations, while light touch, vibration, and position senses are preserved (dissociated sensory loss).
Q-74. All of the following are endocrine manifestations of renal cell carcinoma except
a) Polycythemia
b) Fever
c) Peptic ulcer
d) Renin induced hypertension
Answer: Peptic ulcer
Explanation:
Endocrine manifestations of renal cell carcinoma:
Fever
Erythrocytosis
Hyper-calcemia
Cushing syndrome
Hypertension
Q-75. In which type of renal tubular acidosis hyper-kalemia is a prominent feature
a) Type-I
b) Type II
c) Type III
d) Type IV
Answer: Type IV
Explanation:
Renal tubular acidosis:
Type I: Classical distal
Renal defect- Distal H+ secretion
Serum potassium level- Decreased
Type II: Proximal secretion
Renal defect- Proximal H+
Serum potassium level- Decreased
Type IV: Hyporeninemic hypo-aldosteronism
Renal defect- Distal Na+ reabsorption, K+ secretion and H+ secretion
Serum potassium level-Increased
Q-76. In Fanconi syndrome, failure of tubular re-absorption leads to excessive excretion of except
a) Glucose
b) Phosphate
c) Amino acid
d) Uric acid
Answer: All
Explanation:
Various defects of proximal tubular transport function occur, including impaired resorption of glucose, phosphate, amino acids, HCO3- and uric acid.
Fanconi syndrome causes glucosuria, phosphaturia, generalized aminoaciduria, and HCO3-wasting.
Q-77. Diabetes insipidus is characterized by
a) A decreased urine osmolality, increased serum osmolality
b) A normal urine osmolality, increased serum osmolality
c) A decreased urine osmolality, normal serum osmolality
d) An increased urine osmolality, decreased serum osmolality
Answer: A decreased urine osmolality, increased serum osmolality
Explanation:
Urinary specific gravity of 1.006 or less, and urinary osmolality of less than 200 mOsm/kg are the hallmark of Diabetes insipidus.
Random plasma osmolality generally is greater than 287 mOsm/ kg.
Q-78. Acute attack of gout may be precipitated all except
a) Dietary excess
b) Alcoholic binge
c) Local trauma
d) Use of nitrates for angina
Answer: Dietary excess (?) or Use of nitrates for angina (?)
Explanation:
Acute attacks can be precipitated by several factors, such as increased alcohol consumption, trauma, use of diuretics, dehydration, cyclosporine, diet (organ meat, shellfish), and any drug that can lead to sudden changes (increase or decrease) in urate levels, such as hypo-uricemic agents.
Nitrates contribute to gout by altering blood chemistry and inducing dehydration.
Q-79. Pseudo-membranous colitis is caused by
a) Cl. Perfringens
b) Cl. Welchii
c) Pseudomonas
d) Cl. Difficile
Answer: Cl. Difficile
Explanation:
Antibiotic associated colitis is almost always caused by Cl. Difficile infection.
In patients with severe illness, true pseudo-membranous colitis is seen.
This is characteristic appearance with yellow adherent plaques 2-10 mm in diameter scattered over colonic mucosa interspersed with hyperemic mucosa.
Biopsy reveals epithelial ulceration with classic volcano exudates of fibrin and neutrophils.
Q-80. Respiratory acidosis is seen in all except
a) Fibrosing alveolitis
b) Salicylates poisoning
c) Myasthenia gravis
d) Ext. inter-costal muscle paralysis
Answer: Salicylates poisoning
Explanation:
Respiratory acidosis results from hypo-ventilation and subsequent hypercapnia.
Respiratory alkalosis occurs from hyperventilation and subsequent Hypocapnia.
Respiratory acidosis:
Central nervous system disease or drug-induced respiratory depression
Neuromuscular disease or paralysis (Myasthenia gravis, GB syndrome)
Airway obstruction (Asthma and COPD)
Q-81. All is true about Huntington’s disease except
a) Chorea
b) Behavioral disturbance
c) Early loss of memory loss
d) Cog wheel rigidity
Ans: c
Explanation:
Huntington’s disease:
The most characteristic initial physical symptoms are jerky, random, and uncontrollable movements called chorea.
The clear appearance of symptoms such as rigidity, writhing motions or abnormal posturing appear as the disorder progresses.
Cog-wheel rigidity refers to a body motion (typically the arm) that resembles cogs in a wheel- it’s very jerky and similar to a spring-like action.
Psychomotor functions become increasingly impaired, such that any action that requires muscle control is affected. Common consequences are physical instability, abnormal facial expression, and difficulties chewing, swallowing, and speaking.
Cognitive abilities are impaired progressively. Especially affected are executive functions which include planning, cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions. As the disease progresses, memory deficits tend to appear.
Memory loss is frequently not impaired until late in the disease.
Q-82. A patient has an accident with resultant transection of the pituitary stalk: what will not occur
a) Diabetes mellitus
b) Diabetes insipidus
c) Hyper-prolactinemia
d) Hypothyroidism
Answer: Diabetes mellitus
Explanation:
Pituitary stalk interruption syndrome, also known as pituitary stalk transection syndrome, is characterized by an (1) absent or hypo-plastic adeno-hypophysis, (2) ectopic neuro-hypophysis, and (3) absent or hypo-plastic pituitary stalk.
Q-83. In a patient of acute inferior wall MI; best modality of management is
a) IV fluids
b) Digoxin
c) Diuretics
d) Vasodilators
Answer: IV fluids
Explanation:
RV infarction is present in one third of patients with inferior wall infarction.
It presents with low BP with raised venous pressure with relatively preserved LV function.
Diagnosis is suggested by ST segment elevation in right sided anterior chest leads, particularly RV4.
Treatment consists of fluid loading to improve LV filing and ionotropic agents if necessary.
Q-84. A 26 yr old asymptomatic woman is found to have Arrhythmias and a systolic murmur associated with mid-systolic clicks; which investigation would you use?
a) Electro-physiological testing
b) Tc Scan
c) Echocardiography
d) Angiography
Answer: Echocardiography
Explanation:
Mitral Valve Prolapse or Floppy or Myxomatous mitral valve:
Often associated with skeletal changes (Scoliosis, pectus, straight back) or hyper-reflexivity of joints
Chest pain and palpitations
Murmur pansystolic or only late in systole
Single or multiple mid-systolic clicks
Echocardiography is confirmatory.
Q-85. A patient complains of intermittent claudication, dizziness and headache; likely cardiac lesion is
a) TOF
b) ASD
c) PDA
d) Coarctation of aorta
Answer: Coarctation of aorta
Explanation:
Clinical presentation of coarctation of aorta:
Most patients are asymptomatic.
Headache
Dizziness
Cold extremities and weakness of legs
Claudication with exercise
Epistaxis
Q-86. All of the following are true about ASD except
a) Right atrial hypertrophy
b) Left atrial hypertrophy
c) Right ventricular hypertrophy
d) Pulmonary hypertension
Answer: Left atrial hypertrophy
Explanation:
Atrial septal defect:
The most common form of atrial septal defect is persistence of the ostium secundum in the mid septum.
Echocardiography and Doppler is diagnostic.
The pulmonary pressures are moderately elevated in most patients with ASD.
X-Ray Chest Findings:
Large pulmonary artery
Increased pulmonary vascularity
Enlarged RA and RV
A small aortic knob
Q-87. Mitral valve vegetations do not usually embolise to
a) Lung
b) Liver
c) Spleen
d) Brain
Answer: Lung
Explanation:
Emboli in right side of heart→ tricuspid valve→ pulmonary circulation→ lungs abscess
Emboli in left side of heart→ mitral valve→ systemic circulation→ brain, kidney, spleen etc
Q-88. A woman has septic abortion done; vegetation on tricuspid valve is likely to go to
a) Septic infarcts to lung
b) Liver
c) Spleen infarcts
d) Emboli to brain
Answer: Septic infarcts to lung
Explanation:
Emboli in right side of heart→ tricuspid valve→ pulmonary circulation→ lungs abscess
Emboli in left side of heart→ mitral valve→ systemic circulation→ brain, kidney, spleen etc
Q-89. Kussmaul’s sign is NOT seen in
a) Restrictive cardiomyopathy
b) Constrictive pericarditis
c) Cardiac tamponade
d) RV infarct
Answer: Cardiac tamponade
Explanation:
Kussmaul’s sign is the paradoxical rise in jugular venous pressure with inspiration.
Decreased intra-thoracic pressure during inspiration normally leads to an increase in venous return to the right side of the heart, with an associated decrease in jugular venous pressure.
When there is impaired filling of the right ventricle, the jugular veins instead become engorged.
Causes of Kussmaul’s sign include right ventricular infarction, severe right ventricular failure, restrictive cardiomyopathy, constrictive pericarditis, and tricuspid stenosis.
Q-90. A pt presents with engorged neck veins, BP 80/50 and pulse rate of 100 following blunt trauma to the chest. Diagnosis is
a) Pneumothorax
b) Right ventricular failure
c) Cardiac tamponade
d) Hemothorax
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-91. Best test for assessment of iron status is
a) Transferrin
b) Ferritin
c) Serum iron
d) Hemoglobin
Answer: Ferritin
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-92. Which of the following is not seen on hemoglobin electrophoresis in sickle cell anemia?
a) HbA
b) HbA2
c) HbF
d) HbS
Answer: HbA
Explanation:
Hemoglobin electrophoresis in sickle cell anemia:
HbS: 86-98 %
HbF: 5-15 %
HbA2: 1-3 %
HbA: 0
Hemoglobin electrophoresis in sickle cell trait:
HbS: 40 %
HbF: < 1 %
HbA2: 1-2 %
HbA: 60 %
Q-93. False statement regarding DIC is
a) Thrombocytopenia
b) Decreased fibrinogen
c) Decreased PTT
d) Increased PT
Answer: Decreased PTT
Explanation:
Disseminated intra-vascular coagulation:
Progressive thrombocytopenia
Prolongation of activated partial thromboplastin time (aPTT) and prothrombin time (PT)
Low level of fibrinogen
Elevated D dimer
Q-94. Thrombocytopenia occurs in all except
a) Henoch Schonlein purpura
b) TTP
c) DIC
d) Cavernous hemangioma
Answer: Henoch Schonlein purpura
Explanation:
Causes of Thrombocytopenia:
Decreased production of platelets:
Congenital bone marrow failure- Fanconi anemia and Wiskott Aldrich syndrome
Acquired bone marrow failure- Aplastic anemia, myelo-dysplasia
Marrow infiltration- Neoplastic, infection
Nutritional- Deficiency of vitamin B12, folate, iron; alcohol
Increased destruction of platelets:
Immune thrombocytopenia
Heparin induced thrombocytopenia
Thrombotic micro-angiopathy/ Thrombotic thrombocytopenic purpura (TTP)
DIC
Post transfusion purpura
Mechanical- Aortic valvular dysfunction, extra-corporeal bypass
Hemo-phagocytosis
Increased sequestration of platelets:
Hypersplenism: Cirrhosis, Myelo-proliferative disorder and Lymphoma
Important points:
Henoch-Schönlein 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).
Typical features- Palpable purpura, abdominal pain, arthritis, and hematuria.
A normal platelet count differentiates Henoch-Schönlein purpura from thrombocytopenic purpura.
Q-95. A pt with an Hb of 6, WBC count of 2000, has a normal different count except for having 6% blasts; platelets are reduced to 80,000, moderate splenomegaly is present. Possible diagnosis is
a) Leukemia
b) Aplastic anemia
c) Hemolysis
d) ITP
Answer: Leukemia
Explanation:
Hallmark of acute leukemia is the combination of pancytopenia with circulating blasts. However blasts may be absent in aleukemic leukemia.
The bone marrow is usually hyper-cellular with circulating blasts.
Q-96. A pt being investigated for anemia has a dry marrow tap; peripheral smear reveals tear drop cells; likely diagnosis is
a) Leukemia
b) Lymphoma
c) Myelo-fibrosis
d) Polycythemia Rubra Vera
Answer: Myelo-fibrosis
Explanation:
Myelo-fibrosis is a myelo-proliferative disorder characterized by fibrosis of the bone marrow (Dry tap), splenomegaly, giant abnormal platelets and a leuko-erythroblastic peripheral blood picture with tear drop poikilocytosis.
Fibrosis at early stage is detected by a silver stain demonstrating increased reticulin fibres.
Q-97. Tumor associated with polycythemia Vera is
a) Sarcoma
b) Pituitary adenoma
c) Cerebellar hemangio-blastoma
d) None of the above
Answer: Cerebellar hemangio-blastoma
Explanation:
Tumor associated with polycythemia Vera:
Cerebellar hemangio-blastoma
Meningioma
Hepatoma
Adrenal adenoma
Pheochromocytoma
Uterine fibromyoma
Q-98. A young male with gallbladder stones shows the following test results; serum bilirubin 2.5, Hb 6, urine test positive for urobilinogen. Diagnosis is
a) Hemolytic jaundice
b) Obstructive jaundice
c) Hepato-cellular jaundice
d) Protoporphyria
Answer: Hemolytic jaundice
Explanation:
Hemolytic jaundice:
Anemia
Raised total bilirubin (Raised indirect bilirubin)
Raised serum LDH
Bilirubinate crystals or stone in gall bladder
Presence of urobilinogen in urine
Q-99. An 18 yr old male present with massive hematemesis; he has history of fever for the past 14 days for which he was managed with drugs; moderate spleenomegaly is present; diagnosis is
a) NSAID induced duodenal ulcer
b) Drug induced gastritis
c) Esophageal varices
d) None of the above
Answer: Esophageal varices
Explanation:
Esophageal varices:
Most common presentation: Hematemesis and melena
NSID may be contributing factor for hematemesis.
Splenomegaly
Q-100. Urinalysis shows RBC casts; likely source is
a) Kidney
b) Ureter
c) Bladder
d) Urethra
Answer: Kidney
Explanation:
RBC cast: Glomerular injury
White cell casts: Interstitial injury of kidney
Pigmented muddy brown granular casts: Ischemic or nephro-toxic injury
Broad granular casts: Interstial fibrosis and dilatation of tubules