Recent Questions 2019

Section A
Subject No. of Questions
Anatomy
Physiology
Biochemistry
Pharmacology
Pathology
Forensic Medicine
Microbiology
PSM
Medicine
Surgery
Pediatrics
OBG
ENT
Orthopedics
Dermatology
Ophthalmology
Anaesthesia
Radiology
Psychiatry
Total
 Recent
Questions 2019

ANATOMY
1. Structure derived from first pharyngeal arch: Ans.  (d) Anterior belly of digastric
a. Levator veli palatini b. Buccinator
c. Stylohyoid d. Anterior belly of digastric Ref: Keith L. Moore -The Developing Human 9th Edition
Pg.No: 165

Mesodermal Derivatives of Pharyngeal Arches

Arch Muscular structures Skeletal structures Nerve Artery
1 /
st
Muscles of mastication, Maxilla, zygomatic bone, malleus, Trigeminal nerve Maxillary
mandibular mylohyoid, anterior belly of incus, anterior ligament of malleus, (maxillary and
arch (meckel’s digastric, tensor tympani, tensor sphenomandibular ligament mandibular divisions)
cartilage) veli palatini

2nd / hyoid Muscles of facial expression, Stapes except its footplate, styloid Facial nerve Stapedial
arch stapedius, stylohyoid, posterior process, smaller cornu of hyoid
(reichert’s belly of digastric bone, superior part of body of
cartilage) hyoid, stylohyoid ligament

3rd arch Stylopharyngeus Greater cornu and inferior part of Glossopharyngeal Common
body of hyoid carotid and
internal carotid

4th arch Constrictors of pharynx, Cartilages of larynx except Superior laryngeal Left – arch of
cricothyroid, levator veli palatini arytenoid branch of vagus aorta, Right
– subclavian
artery

6th arch Intrinsic muscles of larynx except Arytenoid cartilage Recurrent laryngeal Left- left
cricothyroid branch of vagus pulmonary
artery, ductus
arteriosus,
right – right
pulmonary
artery
 Section A  Recent Questions 2019

2. Joint involved in movement of head from left to right is? Ans.  (d) Brachioradialis
a. Atlanto axial b. Atlanto occipital
Ref: Last’s Anatomy 9th Edition Pg.No: 433
c. C2- C3 Joint d. C3- C4 Joint
Parathyroid Surgery: Autotransplantation
Ans.  (a) Atlanto axial •• Each parathyroid gland was sliced into 1–3 mm slices
Ref: Gray’s Anatomy 41st Edition Pg.No: 737 and three or four grafts were implanted into separated
•• Atlanto-occipital (between skull and C1) joint permit muscle pockets in the anterior forearm muscles (in
nodding of head ( as when indicating approval or YES) brachioradialis muscle), then the muscle is closed
and Atlanto-axial joint permits the head to be turned with non absorbable sutures. They act as endocrine
from side to side (as indicating disapproval or NO). grafts. This is preferred because in case of recurrent
•• Atlantoaxial is a combination of three synovial joints. hyperparathyroidism, it is easier to approach the arm
The articulation is at three places – a pair of lateral than the neck.
masses and a median complex (between dens of axia 5. Right coronary artery arises from?
and anterior arch & transverse atlantal ligament) a. Right Aortic Sinus
•• Rotation movement tales place simultaneously at all b. Left Aortic Sinus
joints and the normal range of rotation is 40 degrees. c. Posterior coronary sinus
•• The muscles which produce these movements are d. Anterior coronary sinus
obliquus capitis inferior, rectus capitis posterior
major, ipsilateral splenius capitis and contralateral Ans.  (a) Right Aortic Sinus
sternocleidomastoid Ref: Gray’s Anatomy 41st Edition Pg.No: 1016
3. What is the nerve supply of Submandibular gland: •• RCA arises from anterior aortic sinus aka Right aortic
a. Auriculotemporal nerve sinus. Its ostium lies below sinutubular junction.
b. Lingual nerve Though the right artery is single, four ostia have been
c. Glossopharyngeal nerve observed on the right side. This may suggest that there
d. Inferior alveolar nerve exists independent origin of conal, sinuatrial node and
ventricular branches.
Ans.  (b) Lingual Nerve •• LCA arises from left posterior aortic sinus.
Ref: Gray’s Anatomy 41st Edition Pg.No: 528 •• Right posterior aortic sinus is known as “non-coronary
•• The submandibular gland is supplied by autonomic sinus”
fibres of parasympathetic and sympathetic nerves, 6. Which nerve passes through the marked foramen in the
that directly and indirectly regulate salivary secretions given image:
respectively.
Parasympathetic Fibres
•• Originates from the superior salivatory nucleus via pre
synaptic fibres, that travel through the chorda tympani
branch of the facial nerve.
•• The chorda tympani then joins with the lingual
branch of the mandiular nerve before synapsing at the
submandibular ganglion and suspending it by 2 nerve
filaments.
•• Post ganglionic fibres are secretomotor which directly
stimulate the gland to produce secretions, and
vasodilator fibres that accompany arteries to increase
a. Lingual nerve
glandular blood supply.
b. Mandibular nerve
•• Parasymppathetic stimulation increase saliva secretion
c. Chorda tympani nerve
Sympathetic d. Inferior alveolar nerve
•• Sympathetic fibres originate from the superior cervical
ganglion Ans.  (d) Inferior alveolar nerve
•• Sympathetic stimulation reduces glandular blood flow Ref: Gray’s Anatomy 41st Edition Pg. No: 539
through vasoconstriction and decreases the salivary
secretions thereby causing a more mucus and enzyme Marked Area is Mandibular Foramen,
rich saliva. •• Mandibular foramen– opening on the medial surface
4. Parathyroid gland is implanted in which muscle? of the ramus; passageway for the inferior alveolar nerve
a. Sartorius b. Supinator and artery, which supply the lower teeth.
c. Deltoid d. Brachioradialis •• This mandibular foramen leads into mandibular canal
which runs downwards and forwards within the ramus
and ends in the mental foramen.

4
 Section A  Recent Questions 2019

7. Identify the marked muscle ‘A’ in the diagram: 9. Which Nerve Supplied to Area Marked as ‘Area B’ in the
Image:

a. Ulnar nerve
b. Median nerve
a. Brachioradialis c. Radial nerve
b. Extensor carpi radialis longus d. Posterior interosseous nerve
c. Flexor carpi radialis
Ans.  (c) Radial nerve
d. Extensor carpi ulnaris
Ref: Gray’s Anatomy 41st Edition Pg.No: 893
Ans.  (b) Extensor carpi radialis longus
•• At the level of tip of lateral epicondyle, anterior to
Ref: Gray’s Anatomy 41st Edition Pg.No: 852 the elbow, the radial nerve divides into two terminal
•• The extensor carpi radialis longus muscle emerges from branches – superficial branch and the posterior
the lateral epicondyle of the humerus and the distal part interosseous nerve. The superficial branch of radial
of the supraepicondylar ridge; its tendon gets inserted nerve descends down anterolaterally towards the hand
on the dorsal side of the base of second metacarpal. and is related to the roof of the cubital fossa. This branch
•• In proximal areas, it is deep to the brachioradialis supplies whole of the dorsum of the hand and lateral
muscle. 31/2 digits through dorsal digital nerves.
Nerve Supply Other territories marked in the above picture of innervation
•• It is innervated by the main trunk of the radial nerve of dorsum of hand are:
(C6,C7) before it splits into superficial and deep •• Area ‘A’ – palmar digital branches of median nerve
branches. •• Area ‘C’ – dorsal digital branches of ulnar nerve
Action •• Area ‘D’ – posterior cutaneous nerve of forearm
•• It causes extension and abduction of the wrist and the 10. Which of the following is not a boundary of the given
midcarpal joints. image:
8. Duct of Bellini are present in:
a. Pancreas b. Liver
c. Kidney d. Salivary gland

Ans.  (c) Kidney

Ref: Ross & Pawlina’s Histology – 7th edition, Pg. 331
•• Papillary (collecting) ducts are anatomical structures of
the kidneys, previously known as the ducts of Bellini.
•• Papillary ducts represent the most distal portion of the
collecting duct.
•• They receive renal filtrate (precursor to urine) from
several medullary collecting ducts and empty into a
minor calyx. a. Common hepatic duct
•• The area on the papilla which contains the openings of b. Cystic duct
these ducts is called area cribrosa. c. Inferior surface of the liver
d. Gall bladder

5
 Section A  Recent Questions 2019

Ans.  (d) Gall bladder just proximally to the medial epicondyle of the humerus.
•• T2 – At the apex of the axilla.
Ref: Gray’s Anatomy 41 Edition Pg.No: 1175
st
•• T3 – Intersection of the midclavicular line and the third
CALOT’S TRIANGLE intercostal space
•• T4 – Intersection of the midclavicular line and the fourth
•• Calot’s triangle (hepatobiliary triangle) is a small intercostal space, located at the level of the nipples.
anatomical space located at the porta hepatis of the liver •• T5 – Intersection of the midclavicular line and the fifth
– where the hepatic ducts and neurovascular structures intercostal space, horizontally located midway between
enter/exit the liver. the level of the nipples and the level of the xiphoid
The borders are as follows: process.
a.  Medial – common hepatic duct. •• T6 – Intersection of the midclavicular line and the
b.  Inferior – cystic duct. horizontal level of the xiphoid process.
c.  Superior – inferior surface of the liver (segment V). •• T7 – Intersection of the midclavicular line and the
ƒƒ The above differ from the original description of horizontal level at one quarter the distance between
Calot’s triangle in 1891 – where the cystic artery is the level of the xiphoid process and the level of the
given as the superior border of the triangle. umbilicus.
ƒƒ The modern definition gives a more consistent border •• T8 – Intersection of the midclavicular line and the
(the cystic artery has considerable variation in its horizontal level at one half the distance between the level
anatomical course and origin and it is one of the of the xiphoid process and the level of the umbilicus.
contents of the triangle). •• T9 – Intersection of the midclavicular line and the
ƒƒ Other contents include fatty connective tissue, horizontal level at three quarters of the distance
lymphatics, cystic lymph node, autonomic nerves and between the level of the xiphoid process and the level of
rarely accessory bile duct. the umbilicus.
11. Marked area in the given image is supplied by which •• T10 – Intersection of the midclavicular line, at the
dermatome. horizontal level of the umbilicus.
•• T11 – Intersection of the midclavicular line, at the
horizontal level midway between the level of the
umbilicus and the inguinal ligament.
•• T12 – Intersection of the midclavicular line and the
midpoint of the inguinal ligament.
•• L1 – Midway between the key sensory points for T12 and
L2.
•• L2 – On the anterior medial thigh, at the midpoint of a
line connecting the midpoint of the inguinal ligament
and the medial epicondyle of the femur.
a. T8 b. T9
•• L3 – At the medial epicondyle of the femur.
c. T10 d. T11
•• L4 – Over the medial malleolus.
Ans.  (c) T10 •• L5–On the dorsum of the foot at the third metatarsopha-
langeal joint.
Ref: Gray’s Anatomy 41st Edition Pg.No: 233 •• S1 – On the lateral aspect of the calcaneus.
Important Dermatome & Anatomical Landmarks •• S2 – At the midpoint of the popliteal fossa.
•• S3 – Over the tuberosity of the ischium or infragluteal
Following is a list of spinal nerves and points that are
fold
characteristically belonging to the derma-tome of each
•• S4 and S5 – In the perianal area, less than one cm lateral
nerve.
to the mucocutaneous zone
•• C2 – At least one cm lateral to the occipital protuberance
at the base of the skull. Alternately, a point at least 3 cm 12. Identify the type of the fibre marked in the image of
behind the ear. internal capsule:
•• C3 – In the supraclavicular fossa, at the midclavicular
line.
•• C4 – Over the acromioclavicular joint.
•• C5 – On the lateral (radial) side of the antecubital fossa,
just proximally to the elbow.
•• C6 – On the dorsal surface of the proximal phalanx of the
thumb.
•• C7 – On the dorsal surface of the proximal phalanx of the
middle finger.
•• C8 – On the dorsal surface of the proximal phalanx of the
little finger a. Projection fibres b. Short association fibres
•• T1 – On the medial (ulnar) side of the antecubital fossa, c. Long association fibres d. Commissural fibres

6
 Section A  Recent Questions 2019

Ans.  (a) Projection fibres •• This curvilinear bundle of white matter fibre begins as a
group of myelinated fibres known as alveus. The alveus
Ref: Gray’s Anatomy 41 Edition Pg.No: 394
st
joins and form the fimbria of the hippocampus, which
Internal Capsule then thickens spitting off from the hippocampus to form
•• V shaped white matter in the brain which separates the the crus of the fornix.
caudate nucleus and the thalamus from the putamen Fornix Fas 4 parts
and the globs pallidus 1. Crura(seen at splenium of the corpus callosum at the
•• The bend in the V is known as genu level of superior colliculus
•• It has both ascending and descending fibres 2. Commisure (connects crura0
•• In internal capsule, there are axonal fibres that run 3. Body (provides one of the 2 major paths through which
between the cerebral cortex and pyramids of medulla the hippocampus communicate with each other)
4. Columns (anterior pillars) which dive into the
Components
hypothalamus (mammillary bodies)
•• The internal capsule is V-shaped when cut transversely
(horizontally). 14. What is the Nerve Supply of marked structure in the
given image:
When Cut Horizontally:
•• The bend in the V is called the genu
•• Anterior limb of the internal capsule is the part present
infront of the genu.
•• The posterior limb or crus posterius is the part behind
the genu, between the thalamus and lenticular nucleus.
•• The retrolenticular portion is caudal to the lenticular
nucleus and carries optic tracts including the
geniculocalcarine radiations.
•• The sublenticular portion is beneath the lenticular
nucleus and are tracts involved in the auditory pathway
from medial geniculate nucleus to the primary auditory
cortex (Brodmann Area 41).
13. Identify the structure marked by a red arrow in the given
image:

a. Anterior interosseous nerve

b. Posterior interosseous nerve
c. Ulnar nerve
d. Median nerve

Ans.  (d) Median nerve

Ref: Gray’s Anatomy 41st Edition Pg.No: 885
The structure indicated is the first lumbrical muscle of
the hand.
•• The lumbricals belong to the intrinsic group of muscles
which act on the hand.
•• The intrinsic muscles include the following muscles/
a. Great cerebral vein of Galen
groups:
b. Pineal gland
•• Thenar group (act on thumb) – flexor pollicis brevis,
c. Fornix
abductor pollicis brevis, opponens pollicis
d. Falx cerebri
ƒƒ Hypothenar group (act on little finger) – flexor digiti
Ans.  (c) Fornix minimi brevis, abductor digiti minimi, opponens
digiti minimi
Ref: Gray’s Anatomy 41st Edition Pg.No: 385 ƒƒ Adductor pollicis
•• The fornix is the main efferent of the hippocampus and ƒƒ Lumbricals
a vital part of limbic system. The formix has all 3 types of ƒƒ Interosseoi muscles
white fibres - commissural , projection and association ƒƒ Palmaris brevis
fibres. •• All the intrinsic muscles of the hand, except the thenar
•• It is roughy C shaped and extends from the hippocampus muscles and the lateral two lumbrical muscles are
to the mammillary bodies of the hypothalamus and the innervated by the deep branch of the ulnar nerve.
anterior nuclei of the thalamus.

7
 Section A  Recent Questions 2019

•• The thenar muscles and the lateral two lumbrical •• The ducts of sweat glands are free from obstruction
muscles are innervated by the median nerve. because the sweat gland has abnormal concentrations
•• Among the thenar muscles, flexor pollicis brevis is a of inorganic ions, rather than glandular obstruction with
composite muscle - superficial head innervated by thick mucus.
recurrent branch of median nerve and deep head by •• Method of diagnosing CF -Quantitative pilocarpine
deep branch of ulnar nerve. iontophoresis sweat test
15. Identify the marked structure in the image: •• Airway obstruction causes bronchiectasis and atelectasis
•• Obstruction in pancreatic duct causes pancreatitis and
malabsorption
•• Obstruction of bile ducts leads to obstructive jaundice.
17. Boot shape of heart in TOF is due to:
a. Left atrial enlargement
b. Right atrial enlargement
c. Right ventricular hypertrophy
d. Biventricular hypertrophy

Ans.  (c) Right ventricular hypertrophy

Ref: Keith L. Moore -The Developing Human 9th Edition
Pg.No: 321
•• Boot shaped heart. A ‘boot-shaped’ heart (“cœur
en sabot” in French) is the description given to the
appearance of the heart on plain film in some cases of
Tetralogy of Fallot.
•• It describes the appearances of an upturned cardiac
a. Cerebrum b. Brain stem apex due to right ventricular hypertrophy and a concave
c. Corpus callosum d. Cerebellum pulmonary arterial segment.
•• The other defects include pulmonary artery stenosis,
Ans.  (d) Cerebellum ventricular septal defect and dextroposition of aorta.
Ref: Gray’s Anatomy 41st Edition Pg.No: 331 Though cyanosis is one of the classical signs, it is usually
The cerebellum, which stands for “little brain”, is a structure not present at birth.
of the central nervous system. It has an important role in 18. Which of the following structure is not derived from
coordinating the voluntary movements which are initiated external oblique muscle?
by the cerebral cortex. a. Inguinal ligament b. Lacunar ligament
•• The cerebellum is a part of the hindbrain, immediately c. Cooper ligament d. Linea Semilunaris
inferior to the occipital and temporal lobes, and within
the posterior cranial fossa. Ans.  (d) Linea semilunaris
•• It is separated from these lobes by the tentorium Ref: Gray’s Anatomy 41st Edition Pg.No: 1078
cerebelli, a tough layer of dura mater. The external oblique muscle (of the abdomen) (also
•• It lies at the same level of and posterior to the pons external abdominal oblique muscle) is the largest and the
and medulla, from which it is separated by the fourth outermost of the three flat muscles of the anterolateral
ventricle. abdominal wall.
•• The grey matter cerebellar cortex is highly convoluted to The various modifications of the external oblique
accommodate million of neurons in a small area and this aponeurosis are:
arrangement is called “arbor vitae” and consists of four •• Inguinal ligament (Poupart’s ligament) is the folded
nuclei – dentatus, globosus, emboliformis and fastigii. lower border of external oblique aponeurosis
16. Which of the following exocrine glandular ducts are not •• Lacunar ligament (Gimbernat ligament) is the crescent
obstructed in cystic fibrosis: shaped expansion from the medial end of inguinal
a. Pancreas b. Lung ligament attached to pectineal line of pubis.
c. Sweat gland d. All of above •• Pectineal ligament (Cooper’s ligament) is strong fibrous
band extending laterally from the lacunar ligament along
Ans.  (c) Sweat gland pectineal line of pubis.
Ref: Robbins pathological basis of disease 9th Edition Pg.No: •• Reflected part of inguinal ligament extends from the
466 lateral crus of superficial inguinal ring formed by
inguinal ligament upwards to linea alba. It forms the
Abnormal Characteristics of CF Patients posterior wall of inguinal canal.
•• The ducts of the mucus secreting glands are obstructed •• The linea semilunaris (also semilunar line or Spigelian
because of high viscosity of these secretions which leads line) is a curved tendinous intersection found on either
to glandular dilatation and destruction. side of the rectus abdominis muscle. This line extends
from tip of ninth costal cartilagr to pubic tubercle.
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 Section A  Recent Questions 2019

19. Contralateral loss of pain and temperature is due to PHYSIOLOGY

injury to:
a. Anterior spinothalamic tract 22. Testosterone secreted by,
b. Lateral spinothalamic tract a. Gonadotropic cells b. Sertoli cells
c. Fasciculus gracilis c. Acidophilic cells d. Leydig’s cells.
d. Fasciculus cuneatus
Ans. (d)  Leydig’s cells.
Ans.  (b) Lateral spinothalamic tract
Ref - Ganong’s Review of Medical Physiology 25th ed pg 422
Ref: Gray’s Anatomy 41st Edition Pg.No: 299
•• The cells of origin for pain and temperature sensations Testosterone
are located in the various laminae of grey matter of spinal •• C19 steroid with a hydroxyl group in the 17th position
cord. The fibres reach the contralateral spinothalamic •• Testosterone is synthesized from cholesterol in the
tract after decussating in the anterior white commisure leydig cells (by 17 alpha hydroxylase)
of the spinal cord. Close to the brainstem region, the •• Testosterone is also formed androstenedione secreted
axons of lateral spinothalamic tract join with the spinal by adrenal cortex(by 11 and 21 hydroxylases)
lemniscus. Hence damage to lateral spinothalamic tract •• Secretion of testosterone is under the control of LH
leads to loss of pain and temperature on the opposite •• Rate of secretion of testosterone – 4-9mg/d in adult men
side of the body below the level of lesion. •• Plasma testosterone level (free and bound) – 300-
•• Anterior spinothalamic tract carries crude touch and 1000ng/dL in adult men
pressure sensations. Fasciculus gracilis and fasciculus •• 98% of testosterone in plasma is bound to protein (65%
cuneatus carries conscious proprioception, fine touch, -bound to beta globulin / gonadal steroid binding
stereognosis and vibration sensations. globulin / sex steroid binding globulin) and (33% bound
to albumin)
20. Space of Disse is in:
a Spleen b. Lymph node
c. Liver d. Bone

Ans.  (c) Liver

Ref: Gray’s Anatomy 41st Edition Pg.No: 1170
•• The perisinusoidal space (or space of Disse) is a narrow
gap between a plate of hepatocytes and a sinusoid.
•• The width of this perisinusoidal space is 0.2-0.5
micrometre.
•• Microvilli of hepatocytes, stellate cells, interstitial fluid
and collagen fibres are the major constituents of this
space.
21. What are Gitter cell?
a. Macroglia
b. Modified macrophage in CNS
c. Astrocytes Image courtesy – Ganong’s Review of Medical Physiology
d. Oligodendrocytes 25th ed
Ans.  (b) Modified macrophages in CNS Mechanism of action and actions of Testosterone
Gitter Cells:
•• These cells are macrophages and because of their
appearance they are called “gitter cells”.
•• They look this way because they are lipid-laden.
•• These macrophages are thought to be mainly derived
from circulating blood monocytes, but some probably
originate from resident microglia.
•• Any time there is parenchymal damage (e.g.
inflammation, infarction, parasite migration) these
cells will phagocytose lipid from degenerate myelin and
cellular debris.
•• These lipid-laden macrophages migrate to the
perivascular spaces and leave the CNS via the blood or
CSF.
Image courtesy – Ganong’s Review of Medical Physiology
25th ed

9
 Section A  Recent Questions 2019

•• Testosterone binds to an intracellular receptor

Decreased ECF volume Increased ECF volume
•• The receptor/steroid complex then binds to DNA in the
nucleus Pain, emotion, “stress” Alcohol
•• This facilitates the transcription of many genes exercise
•• In addition, testosterone is also converted to Nausea and vomiting
Dihydrotestosterone by 5 alpha reductase in some target
Standing
cells. DHT binds to the same intracellular receptor as
testosterone Clofibrate, carbamazepine
Congenital 5 Alpha Reductase Deficiency Angiotensin II
•• Mutation of gene for type 2 5 alpha reductase 24. All are true about Decerebrate posture EXCEPT:
•• Causes male pseudohermaphroditism a. Extension of both upper and lower extremity
•• Individuals born with male internal genitalia including b. Flexion of upper extremity and extension of lower
testes, but have female external genitalia and usually extremity
raised as girls c. Exaggerated gamma motor neuron discharge
•• On reaching puberty, lh and testosterone levels raise d. Reticulo spinal tract is also involved
and they usually change their gender identities and
become boys Ans. (b) Flexion of upper extremity and extension of
•• Penis at 12 syndrome - clitoris enlarges to the point lower extremity
that some individuals can have intercourse with
Ref - Ganong’s Review of Medical Physiology 25th ed pg243
women
Decorticate Rigidity Decerebrate Rigidity
5 alpha reductase inhibitors (finasteride) - used to treat
benign prostatic hyperplasia •• Removal of cerebral cortex •• Complete transection
•• Corticospinal tract is cut off of brainstem between
23. Aquaporin channel mediated through ADH: •• Intact Rubrospinal tract superior and inferior
a. GLUT b. Aquaporin 1
( which causes flexion of colliculi (midcollicular
c. Aquaporin 2 d. Aquaporin 3
upper limbs) cerebration)
Ans.  (c) Aquaporin 2 •• Intact reticulospinal tract ( •• Corticospinal tract is cut off
which causes extension of •• Rubrospinal tract is cut off
Ref - Ganong’s Review of Medical Physiology 25th ed pg 696 of limbs) •• Intact reticulospinal tract (
Vasopressin •• So the net effect is that which causes extension of
there is flexion of upper upper and lower limbs –
•• Vasopressin – secreted by suprachiasmatic nuclei of
limbs and extension of due to its excitatory effect
hypothalamus and transported to posterior pituitary
lower limbs of gamma motor neurons,
•• Biologic half life – 18 min
•• This type of rigidity is seen which indirectly activates
•• Vasopressin receptors
on the hemiplegic side the alpha motor neurons)
V1A and V1B after haemorrhages or •• So the net effect is that
•• G protein coupled receptor that acts via thromboses in the internal there is extension of both
phosphatidylinositol hydrolysis to increase intracellular capsule upper and lower limbs
Ca++ concentration •• This type of rigidity can
•• V1A – mediate vasoconstrictor effect occur after uncal herniation
•• V1B - also called V3 receptors- specific to anterior pituitary
– mediate secretion of ACTH
V2
•• G protein coupled receptor that acts through Gs to
increase cAMP
•• Antidiuretic action 25. Bainbridge reflex is due to
•• Mechanism of action – insertion of aquaporin 2 into the a. Stretching of atria
apical membranes of the principal cells of collecting b. Baroreceptor reflex
duct c. Decreased venous return
Factors Affecting Vasopressin Secretion d. Increased ventricular activity

Ans.  (a) Stretching of atria

Vasopressin Secretion Vasopressin Secretion
Increased Decreased Ref;Guyton and Hall Textbook of Medical Physiology 13th ed
pg-268
Increased effective osmotic Decreased effective
pressure of plasma osmotic pressure of plasma
Contd…

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 Section A  Recent Questions 2019

Bain Bridge Reflex 28. Peripheral chemoreceptors respond to hypoxia using

which channel?
a. Calcium channel b. Sodium channel
c. Potassium channel d. Chloride channel

Ans.  (c) Potassium channel

Ref; Boron Medical Physiology 2nd ed pg 738
Peripheral chemoreceptors
•• Carotid bodies and aortic bodies (these carotid bodies
and aortic bodies should not be confused with the
baroreceptors of carotid sinus and aortic arch)
•• The major function of these carotid and aortic bodies
is to sense hypoxia in the arterial blood and send
signals to the medulla to increase ventilation
26. Function of Golgi tendon organ is to detect •• The signals are carried through afferents of vagus for
a. Tension b. Length aortic bodies and glossopharyngeal nerve for carotid
c. Pressure d. Proprioception bodies
•• The glomus cell is the chemosensor in the carotid and
Ans.  (a) Tension aortic bodies
Ref - Ganong’s Review of Medical Physiology 25th ed pg232 Response of Glomus Cells to Hypoxia

Stretch Reflex Inverse Stretch Reflex

(Myotactic reflex) (Lengthening reflex)
Monosynaptic reflex Disynaptic reflex
Stimulus – muscle Stimulus – Change in muscle
stretch(change in muscle tension
length)
Receptor – muscle spindle Receptor – Golgi tendon organ
Afferent – I a and II Afferent – I b
Centre – spinal cord Centre – spinal cord
Efferent – alpha motor neuron Efferent – alpha motor neuron
Effect – muscle contraction Effect – muscle Relaxation

27. Hormone predominantly secreted after 14 day on

endometrium is?
a. Progesterone b. Estrogen 29. With increase in age which of the following is true for
c. LH d. FSH lungs?
a. Pulmonary compliance increases
Ans.  (a) Progesterone b. Residual volume decreases
Ref;Guyton and Hall Textbook of Medical Physiology 13th ed c. Mucocillary clearance increases
pg 665 d. The alveolar dead space decreases

Ans.  (a) Pulmonary compliance increases

Ref - Relationship between chest wall and pulmonary
compliance and age Charles Mittman, Norman H. Edelman,
Arthur H. Norris, and Nathan W. Shock 01 NOV 1965https://
doi.org/10.1152/jappl.1965.20.6.1211
Ageing and Lung Changes
•• Decreased chest wall compliance is counterbalanced
by a loss of elastic recoil of the lungs (increased lung
compliance), which is due to a decrease in the number
of parenchymal elastic fibers.
•• Chest wall and thoracic spine deformities which leads to
increase work of breathing.
•• Dilation of air spaces: “senile emphysema”.
11
 Section A  Recent Questions 2019

•• Respiratory muscle strength decreases with age and this 32. Calcitonin levels increased in
impairs effective cough, which is important for airway a. Hyperthyroidism b. Hypoparathyroidism
clearance. c. Hyperparathyroidism d. Cushing Syndrome
•• Clearance of particles from the lung through the
mucociliary elevator is decreased and associated with Ans.  (b) Hyperparathyroidism
ciliary dysfunction. Calcitonin secretion is stimulated by increased serum
•• The alveolar dead space increases with age, affecting calcium concentration and calcitonin protects against the
arterial oxygen without impairing the carbon dioxide development of hypercalcemia
elimination.
33. Fev1=1.3 & FCV=3.9
•• The airways receptors undergo functional changes
with age and are less likely to respond to drugs used in Which of the following does this signify?
younger counterparts a. Normal lung function
•• Decreased sensation of dyspnea and diminished b. Obstructive lung disease
ventilatory response to hypoxia and hypercapnia, c. Restrictive lung disease
making them more vulnerable to ventilatory failure d. Both
during high demand states (ie, heart failure, pneumonia,
Ans.  (b) Obstructive lung disease
etc)
•• Decreases in the volume of the thoracic cavity and Ref;Guyton and Hall Textbook of Medical Physiology 13th ed
reduced lung volumes. Hence Residual volume increases pg 346
30. Functional residual capacity represents the volume of •• The graph shows that FVC does not change greatly
air remaining in lungs between normal and obstructive patients
a. After normal inspiration b. After normal expiration •• However, there is a major difference in the amounts of
c. After forceful expiration d. After forceful inspiration air that these persons can expire each second, especially
during the first second (FEV1)
Ans.  (b) After normal expiration •• In normal person FEV1/FVC is 80%
Ref - Ganong’s Review of Medical Physiology 25th ed pg 629 •• In airway obstruction, the value decreases to nearly 47%
•• In serious airway obstruction as in acute asthma, the
•• Functional residual capacity is the volume of air value can decrease to less than 20%
remaining in the lungs after expiration of a normal •• In the given question FEV1/FVC is 33.3%. Therefore
breath denotes obstruction
•• Normal value – 2.5 L
•• (Residual volume + Expiratory reserve volume)
31. Tubuloglomerular feedback control is useful for which
one of the following?
a. GFR
b. Plasma sodium
c. Plasma volume
d. Determining tubular secretion

Ans.  (a) GFR.

Ref - Ganong’s Review of Medical Physiology 25th ed pg 682
Tubuloglomerular feedback

34. Antegrade peristalsis due to?

a. Ach b. Serotonin
c. Substance P d. VIP

Ans.  (d) VIP

Ref; Physiology of the Gastrointestinal Tract (Sixth Edition),
2018

12
 Section A  Recent Questions 2019

•• Peristalsis can be defined as a motor pattern of the gut

organ musculature that can propel content into the anal
(antegrade  peristalsis) or oral (retrograde  peristalsis)
direction
•• Impulses travelling orad activate ascending contraction:
•• Neurotransmitters here are acetylcholine, substance P,
and neuro-kinin A.
•• Impulses travelling caudad activate descending
relaxation:
•• Neurotransmitters here are VIP, NO, and PACAP
(pituitary adenylyl cyclase activating polypeptide).
35. C-peptide is seen
a. In Pre-proinsulin
b. In Proinsulin
c. As a combined entity with insulin after secretion
d. As a gastrointestinal proactive molecule
•• Respiratory center is composed of a group of neurons
Ans.  (b) In proinsulin located bilaterally in the medulla oblongata and pons.
•• The respiratory centers are
Ref - Ganong’s Review of Medical Physiology 25th ed pg431 •• Dorsal respiratory group- located in dorsal medulla and
mainly causes inspiration
Insulin •• Ventral respiratory group - located in ventrolateral
•• Insulin is synthesized in the rough endoplasmic medulla and mainly causes expiration. This area
reticulum of the B cells operates as an overdrive mechanism when high levels
•• The gene for insulin is located on the short arm of of pulmonary ventilation are required, especially during
chromosome 11 in humans. heavy exercise or forceful expiration
•• Normally, 90–97% of the product released from the •• Pneumotaxic center – located dorsally in the superior
B cells is insulin along with equimolar amounts of C portion of the pons, and mainly control rate and depth
peptide. of breathing
•• C peptide can be measured by radioimmunoassay, 37. Slow conduction velocity is seen with which of the
it is an index of B cell function in patients receiving following nerve fibers?
exogenous insulin. a. Preganglionic autonomic nerve fibers
b. Postganglionic autonomic nerve fibers
c. Motor nerves
d. Sympathetic nerve fibers

Ans.  (b) Postganglionic nerve fibers.

Ref - Ganong’s Review of Medical Physiology 25th ed pg94
Erlanger & Gasser Classification of Sensory Nerve Fibres

Fiber type Function Fiber Conduction

Diameter velocity
(mm) (m/s)
Aa Proprioception; 12-20 70-120
somatic motor
Ab Touch, pressure 5-12 30-70
Ag Motor to muscle 3-6 15-30
36. In forceful expiration, which of the following neurons spindles
gets fired? Ad Pain, temperature 2-5 12-30
a. VRG b. DRG
c. Pneumotaxic centre d. Chemoreceptors B Preganglionic <3 3-15
autonomic
Ans.  (a) VRG C, Dorsal root Pain, temperature 0.4-1.2 0.5-2
C, sympathetic Postganglionic 0.3-1.3 0.7-2.3
sympathetic

13
 Section A  Recent Questions 2019

Also Remember
A fibres are the
•• Largest
•• Fastest
•• Myelinated
C fibres are
•• Smallest
•• Slowest
•• Unmyelinated

BIOCHEMISTRY
38. Zellweger syndrome is due to absence of
a. Lysosomal b. Peroxisome 40. Which of the following is not the source of cytosolic
c. Mitochondria d. Cytosol NADPH ?
a. ATP citrate lyase
Ans.  (b) Peroxisome b. Isocitrate dehydrogenase
c. Malic enzyme
(Ref : Harper 30/e : p 241,614 ) d. 6-phospho gluconate dehydrogenase
•• Zellweger syndrome is also called cerebrohepatorenal
syndrome , due to defective oxidation of very long chain Ans.  (a) ATP citrate lyase
fatty acids (VLCFA). (Ref : Harper 30/e : p 197 )
•• Due to mutations in genes (PEX family of genes:
peroxins) involved in the biogenesis of peroxisomes  •• Glucose-6-phosphate dehydrogenase in HMP SHUNT
Peroxisomal enzymes are produced; but their entry into pathway (Glucose-6-phosphate → 6-phospho-glucono
peroxisome is denied  insufficient oxidation of VLCFA lactone)
 Accumulation of VLCFA in CNS causes neurological •• 6-phospho gluconate dehydrogenase in HMPshunt
impairment and death in childhood. pathway (6-phospho gluconate → 3-keto-6-phospho
•• This condition is apparent at birth and is characterized gluconate)
by profound neurologic impairment, victims often dying
within a year.
•• Biochemical findings include an accumulation of very-
long-chain fatty acids, abnormalities of the synthesis of
bile acids, and a marked reduction of plasmalogens.
39. Urea, creatinine, nitric oxide formed by which amino
acid
a. Histidine b. Aspartate
c. Methionine d. Arginine

Ans.  (d) Arginine

(Ref : Harper 30/e : p 314, 321)
•• Arginine provides the formamidine group of creatine •• Cytoplasmic isocitrate dehydrogenase
and the nitrogen of NO and via ornithine, provides the •• Malic enzyme (malate to pyruvate).
skeleton of the polyamines putrescine, spermine, and
41. All are true regarding mitochondrial DNA, EXCEPT ?
spermidine.
a. All respiratory proteins are synthesized within
•• The final reaction of UREA cycle is the hydrolysis of
mitochondria itself
arginine to urea and ornithine by arginase
b. Double stranded
c. High mutation rate
d. Inherited from mother

Ans.  (a)  All respiratory proteins are synthesized within

mitochondria itself
(Ref : Harper 30/e : p 378 )

14
 Section A  Recent Questions 2019

in cirrhosis ,portal blood bypass the liver, systemic blood

•• Is circular, double-standed, and composed of heavy (H)
ammonia may attain toxic levels.
and light (L) chains of stands
•• Symptoms of ammonia intoxication include tremor,
•• Contains 16,569 bp slurred speech, blurred vision, coma, and ultimately
•• Encodes 13 protein subunits of the respiratory chain death.
(of a total of about 67) •• Ammonia may be toxic to the brain in part because it
„„ Seven subunits of NADH dehydrogenase (complex I) reacts with a-ketoglutarate to form glutamate.
„„ Cytochrome b of complex III •• The resulting depletion of levels of a-ketoglutarate then
„„ Three subunits of cytochrome oxidase (complex IV) impairs function of the tricarboxylic acid (TCA) cycle in
„„ Two subunits of ATP synthase
neurons.

•• Encodes large (165) and small (125) mt ribosomal RNAs NAD(P)+ NADPH + H+
•• Encodes 22 mt RNA molecules NH3
•• Genetic code differs slightly from the standard code L-Glutamate α-Ketoglutarate
„„ UGA (standard stop codon) is read as Trp
„„ AGA and AGG (standard codons for Arg) are read as 44. Which amino acid is used to synthesis Nitric oxide ?
stop codons a. Glycine b. Arginine
•• Contains very few untransiated sequences c. Tyrosine d. Histidine
•• High mutation rate (5-10 times that of nuclear DNA) Ans.  (b) Arginine
•• Comparisons of mtDNA sequences provide evidence
(Ref: Harper 30/e : p 314)
about evolutionary origins of primates and other
species Arginine Citrulline + NO
•• Maternal inheritance: Since, the mitochondria are 2 O2
inherited cytoplasmically, the mtDNA is inherited from
the mother 3/2 NADPH + H+ 3/2 NADP+
•• Defects in mitochondrial genome will lead to •• The reaction catalyzed by Nitric oxide Synthase, contains
mitochondrial myopathies heme, FAD, FMN and tetrahydrobiopterine. The enzyme
42. Which apolipoprotein is responsible for Alzeihmers utilizes NADPH and molecular oxygen.
disease •• The guanidino nitrogen of arginine is incorporated into
a. APOE3 b. APOE1 NO˙.
c. APOE4 d. APOE2 •• From the molecular oxygen, one atom is added to NO˙
and the other into citrulline.
Ans.  (c) APOE4 •• Therefore, the enzyme is a di-oxygenase
(Ref : Harper 30/e : p 275) •• NO, an intercellular signaling molecule that serves
as a neurotransmitter, smooth muscle relaxant, and
•• Familial AD and Apo-E4 gene: There is an association
vasodilator
between patients possessing the apo E4 allele and
the incidence of Alzheimer disease. Apparently, apo 45. Menkes disease is associated with which enzyme
E4 binds more avidly to β-amyloid found in neuritic deficiency.
plaques. a. Methionine synthase b. Glutamyl aminopeptidase
•• Genes identified with AD are that coding for c. Lysyl oxidase d. Lysyl hydroxylase
APP, presenilin-1 (chromosome 14), presenilin-2
Ans.  (c) Lysyl oxidase
(chromosome 1) or AD3 (chromosome 14) or AD4
(chromosome 1), and Apo-E4 gene (chromosome 19). (Ref : Harper 30/e : p 281,631 )
•• The presence of Apo-E4 gene is the major risk factor for •• Menkes syndrome, characterized by kinky hair and
AD. Apo-E2 gene reduces the risk of AD. growth retardation, results from a dietary deficiency
43. Hyperammonaemiainhibit TCA cycle  by depleting? of copper, an essential cofactor for the enzyme lysyl
a. Aspartate b. Malate oxidase that functions in formation of the covalent cross-
c. a keto glutarate d. Fumarate links that strengthen collagen fibers.
•• Defects in ATP7A result in Menkes disease
Ans. (c) a keto glutarate
46. LCAT deficiency increases the following
(Ref : Harper 30/e : p 291, 292 , Lippincott7/e : P 253) a. HDL b. IDL
•• Since ammonia is toxic to CNS , it is essential to maintain c. VLDL d. Chylomicrons
only traces (10-20 μg/dL) in peripheral blood.
Ans.  (a) HDL
•• In severely impaired hepatic function orthe development
of collateral links between the portal and systemic veins (Ref : Harper 30/e : p 249, 272)

15
 Section A  Recent Questions 2019

•• HDL is synthesized and secreted from both liver and •• Mothers also have hyperammonemia and an aversion to
intestine high protein diet
•• Lecithin: cholesterol acyltransferase (LCAT) activity is •• Elevated levels of ammonia are associated with high
associated with HDL containing apo A-I. glutamine levels in CSF, blood and urine
•• As cholesterol in HDL becomes esterified, it creates a •• Orotic aciduria due to channelling of carbamoyl
concentration gradient and draws in cholesterol from phosphate into Pyrimidine synthesis
tissues and from other lipoproteins thus enabling HDL 49. True about type 1 diabetes mellitus
to function in reverse cholesterol transport a. Increased lipolysis
•• Absence of LCAT leads to block in reverse cholesterol b. Decreased protein catabolism
transport. HDL remains as nascent disks incapable of c. Decreased hepatic Glucose output
taking up and esterifying cholesterol. d. Increase glucose uptake
47. A 25 year old alcoholic presented with edema, hyperten-
sion, ocular disturbance and changes in mental state Ans.  (a) Increased lipolysis
was observed, diagnosis of high output cardiac failure (Ref : Harper 30/e : p 149)
was made with Wet Beri Beri, this is due to deficiency of?
•• Patients may become hyperglycemic in poorly controlled
a. Vit B3 b. Vit B1
type 1 diabetes mellitus . The reason being - due to lack
c. Vit B12 d. Vit B6
of insulin to stimulate uptake and utilization of glucose
Ans.  (b) Vit B1 and also because in the absence of insulin which
antagonize the actions of glucagon, there is increase in
(Ref : Harper 30/e : p 555 ) gluconeogenesis from amino acids in liver.
Deficiency Manifestations of Thiamine/ vitamin B1 / •• Lack of insulin (which antagonize the actions of
Aneurine or antiberberi factor: glucagon) results in increased lipolysis in adipose
Beri Beri tissue , and the resultant NEFAs become substrates for
•• Early symptoms include anorexia, dyspepsia, heaviness ketogenesis in the liver. There is defect in the utilization of
and weakness ketone bodies in muscle because of lack of oxaloacetate .
•• In uncontrolled diabetes, ketosis is severe enough to
Wet Beri Beri
cause pronounced acidosis (ketoacidosis).
•• Most prominent are CVS manifestations
•• Coma results from both the acidosis and also the
•• Main features are edema of legs, face, trunk and serous
considerably increased osmolality of extracellular fluid
cavities
(mainly as a result of the hyperglycemia, and diuresis
•• Other findings include palpitation, breathlessness and
resulting from the excretion of glucose and ketone
distended neck veins
bodies in the urine).
•• Death due to heart failure
50. Protein which is not synthesised in liver is
Dry Beri Beri a. Acute Phase protein b. Albumin
•• Major features are CNS manifestations c. Plasma hormone d. Immunoglobulins
•• Peripheral neuritis with sensory disturbance may cause
complete paralysis Ans.  (d) Immunoglobulins
Infantile Beri Beri (Ref : Harper 30/e : p 670, 681)
•• Seen in infants born to mothers suffering from thiamine
deficiency •• Almost 70% to 80% of all plasma proteins except
•• Restlessness and sleeplessness are also seen immunoglobulins are synthesized in liver .
•• Plasma proteins are generally synthesized on
Wernicke Korsakoff Syndrome/Cerebral Beri Beri membrane-bound polyribosomes.
•• Encephalopathy (ophthalmoplegia, nystagmus, •• These include:
cerebellar ataxia) and psychosis
F. Polyneuritis Carrier Proteins or Transport Proteins of Plasma:
•• Albumin, Fibrinogen
48. Glutamine is increase in CSF, blood and urine, this is due
•• Prealbumin (Transthyretin)
to deficiency of
•• Retinol binding protein (RBP)
a. OTC
b. Argininosuccinatelyase •• Thyroxine binding globulin (TBG)
c. CPS -I •• Transcortin; Cortisol binding globulin (CBG)
d. Argininosuccinatesynthetase •• Haptoglobin (Hp)
•• Hemoglobin a2
Ans.  (a) OTC •• Transferrin
•• Hemopexin
(Ref : Harper 30/e : p 295 ) Acute phase proteins: (CRP, Ceruloplasmin ,Alpha-1
•• Ornithine transcarbamoylase deficiency/ Antitrypsin, Alpha-2 Macroglobulin etc
Hyperammonemia Type II is the only urea cycle disorder, Immunoglobulins are secreted by plasma cells belonging
which is inherited as an X-linked trait. to the B-lymphocytes.

16
 Section A  Recent Questions 2019

51. Type of cholesterol present in gallstones?

IV Basement XVIII Assoicated with
a. Amorphous cholesterol monohydrate.
membranes collagens close to
b. Amorphous cholesterol dehydrate + potassium
basement membranes,
bilirubinate.
close structural
c. Crystalline Cholesterol dihydrate.
homologue of XV
d. Crystalline cholesterol monohydrate.
V Minor component XIX Rare, basement
Ans.  (d) Crystalline cholesterol monohydrate. in tissue containing membranes,
collagen I rhabdomyosarcoma
(Ref : Harper 30/e : p 537 )
cells
•• Components :cholesterol monohydrate crystals, calcium
bilirubinate, and bile salts. VI Muscle and most XX Many tissues,
•• Small changes in the composition of bile can result in connective tissue particularly corneal
crystallization of cholesterol as gallstones epithelium
•• The gallbladder stores bile salts produced by the liver, VII Dermal-epidermal XXI Many tissues
which acts to emulsify fats, helping with the digestion of junction
fat. VIII Endothelium and XXII Tissue junctions,
•• Gallstones form when the solutes in the gallbladder other tissues including cartilage-
precipitate. synovial fluid, hair
•• Cholesterol stones (80% of gallstones) are usually yellow- follicle-dermis
green in appearance
•• Patients may have pain (epigastric or right upper IX Tissues containing XXIII Limited in tissues,
quadrant and radiating to the right shoulder )from the collagen II mainly transmembrane
gallstones, usually after a fatty meal. and shed forms
•• If the gallbladder becomes inflamed or infected, X Hypertrophic XXIV Developing cornea and
cholecystitis can result. cartilage bone
•• The stones can also travel through the bile duct and XI Tissues containing XXV Brain
obstruct biliary flow leading to jaundice, or irritate the collagen II
pancreas and cause pancreatitis.
XII Tissues containing XXVI Testis, ovary
52. Collagen present in skin is
collagen I
a. Type II b. Type V
c. Type I d. Type IV XIII Many tissues, XXVII Embryonic cartilage
including and other developing
Ans.  (c) Type I neuromuscular tissues, cartilage in
junctions and skin adults
(Ref : Harper 30/e : p 628 , Lippincott 7/e: P 44)
•• Collagen is the most abundant protein in the human XIV Tissues containing XXVIII Basement membrane
body,have a triple helical structure collagen I around Schwann cells
•• At least 28 distinct types of collagen made up of over 53. Which of the following is not Ribozyme?
30 distinct polypeptide chains have been identified in a. Ribonuclease
human tissues b. Poly A polymerase
•• The main fibril forming collagens in skin and bone and c. Transpeptidase
in cartilage, respectively, are types I and II d. Peptidyl Transferase
Type Distribution Type Distribution Ans.  (b) Poly A polymerase
I Noncartilaginous XV Associated with (Ref : Harper 30/e : p 363,409 )
connective tissues, collagens close to
including bone, basement membranes •• Ribozymes or RNA enzymes are catalytic RNA molecules
tendon, skin in many tissues with sequence specific cleavage activity.
including in eye, muscle, •• E.G : Spliceosomes , RNAse-P - generates the ends
microvessels of tRNAs, Peptidyl transferase - used for protein
biosynthesis
II Cartilage, vitreous XVI Many tissues •• Poly(A) tails are added to the 3′ end of mRNA molecules
humor in a post transcriptional processing.
III Extensibile XVII Epithelia, skin •• Poly(A) polymerase, adds a poly(A) tail which is
connective tissue, hemidesmosomes subsequently extended to 200 A residues.
including skin, lung, •• The poly(A) tail both protects the 3′ end of mRNA from 3′
vascular system → 5′ exonuclease attack and facilitates translation.
Contd...

17
 Section A  Recent Questions 2019

54. Type-I hyperlipoproteinemia is characterized by •• Rivaroxaban inhibits free and clot associated Factor
a. Elevated LDL Xa  reducing Thrombin generation  suppressing
b. Elevated HDL Platelet aggregation and Fibrin formation.
c. Elevated lipoprotein lipase •• Other options:
d. Elevated chylomicrons ƒƒ Dabigatran etexilate is an Oral Direct Factor IIa
(Thrombin) Inhibitor
Ans.  (d) Elevated chylomicrons ƒƒ Fondaparinux is a parenteral synthetic Heparin
(Ref : Harper 30/e : p 275 ) derivative anticoagulant
ƒƒ Bivalirudin is a parenteral Hirudin-based Thrombin
•• Hyperlipoproteinemia I / Familial lipoprotein lipase
Inhibitor.
deficiency (type I) - autosomal recessive
•• Salient features of Rivaroxaban:
•• Fasting chylomicronemia and Hypertriacylglycerolemia
due to deficiency of LPL, abnormal LPL, or apo C-ll
deficiency causing inactive LPL.
•• Slow clearance of chylomicrons and VLDL.
•• Low levels of LDL and HDL.
•• No increased risk of coronary disease.
•• Eruptive xanthoma; hepatomegaly; Pain abdomen are
seen
•• It usually manifests in young age.
•• A chylomicron band in fasting plasma is the characteristic
finding.
55. In Kreb’s cycle and Urea cycle the linking amino acid is
a. Arginine b. Ammonia
c. Fumarate d. Aspartate

Ans.  (c) Fumarate

•• Routine coagulation profile monitoring is not useful;
(Ref : Harper 30/e : p 294) Factor Xa assays are more specific for monitoring
•• Cleavage ofargininosuccinateby argininosuccinatelyase, the anticoagulant action of oral Factor Xa inhibitors.
results in formation of arginine and release of the Routine/ Yearly assessment of renal parameters are
aspartate skeleton as fumarate (funnelled into TCA recommended.
cycle) 57. A nursing mother presented with fever and breast
•• Subsequent addition of water to fumarate forms l-malate, tenderness after two weeks postpartum. Which oral
with subsequent oxidation forms oxaloacetate, followed antibiotic is ideal for her condition?
by its transamination by glutamate aminotransferase a. Ampicillin b. Dicloxacillin
then re-forms aspartate. c. Ceftazidime d. Ciprofloxacin
•• Argininosuccinate synthase links aspartate and citrulline
forms argininosuccinate. Ans.  (b) Dicloxacillin
•• Thus the urea cycle is linked to TCA cycle through
fumarate Ref: Harrisons Principles of Internal Medicine, 20th Ed.,
Pg.No: 1079.
•• Peurperal Mastitis is a skin & soft tissue infection caused
PHARMACOLOGY by Staphylococcus aureus that occurs in 1-3% of nursing
mothers after 2-3 weeks postpartum.
56. Oral Factor Xa Inhibitor is: •• It presents with features ranging from signs of local
a. Dabigatran etexilate b. Rivaroxaban breast inflammation (cellulitis to abscess) associated
c. Fondaparinux d. Bivalirudin with systemic signs of fever, chills, malaise, anorexia,
lethargy, etc. in severe cases.
Ans.  (b) Rivaroxaban •• Dicloxacillin is an acid stable β-lactamase resistant
Ref: Goodman & Gilman’s the pharmacological basis of anti-Staphylococcal Penicillin – the preferred treatment
therapeutics.13th Edition. Pg:594. choice for penicillinase-producing Staphylococcus
aureus and Staphylococcus epidermidis that are not
•• Oral Direct Factor Xa (Stuart-Prower factor) Inhibitors methicillin resistant.
are Rivaroxaban, Apixaban, Betrixaban and Edoxaban

18
 Section A  Recent Questions 2019

59. DOC for prophylaxis against Diphtheria:

Drug Therapy for Skin and Soft Tissue Infections Caused
a. Erythromycin b. Rifampicin
by Staphylococus Aureus
c. Cloxacillin d. Ciprofloxacin
Drug of Methicillin Sensitive Methicillin Resistant
Choice Strains Strains Ans.  (a) Erythromycin
•• Dicloxacillin 500mg •• Minocycline or Ref: Harrisons Principles of Internal Medicine, 20th Ed.,
QID Doxycycline 500mg BD Pg.No: 1098.
•• Cephalexin 500mg •• Cotrimoxazole 1or 2 •• Chemoprophylaxis against Diphtheria:
First Line QID DS BD ƒƒ Close contacts are subjected to throat cultures to
Drugs •• Cefadroxil 1g BD •• Clindamycin 300- establish their carrier status.
450mg TID ƒƒ Irrespective of culture results, all contacts are started
•• Linezolid 600mg BD on chemoprophylaxis.
•• Tedizolid 200mg OD ƒƒ Chemoprophylaxis Drug options:
•• Minocycline or •• Vancomycin (15–20 ŠŠ Oral Erythromycin (1g/day for adults; children –
Doxycycline 500mg mg/kg q8–12h) 40mg/Kg/day): once a day for 7-10 days in patients
BD •• Daptomycin (6–10 mg/ over 6 months of age.
•• Cotrimoxazole 1or 2 kg IV q24h) ŠŠ IM Benzathine Penicillin G (1.2 MU) one dose
Alternate
DS BD for contacts >6 years. Half the dose in paediatric
Drugs
•• Clindamycin 300- contacts less than 6 years.
450mg TID
•• Linezolid 600mg BD
•• Tedizolid 200mg OD

58. High plasma protein binding of a drug results in:

a. Decreased glomerular filtration
b. High volume of distribution
c. Lowers duration of action
d. Less drug interaction

Ans.  (a) Decreased glomerular filtration.

Ref: HL & KK Sharma’s Principles of Pharmacology, 3rd Ed.
Pg. No: 48.
•• Most drugs bind to plasma proteins in a reversible
fashion without translating into a pharmacological
response. (Plasma proteins are hence called Silent
Receptors)
•• Acidic drugs bind to Albumin, Basic drugs to a1 acid-
glycoprotein.
•• Binding of the drug to plasma protein affects the
pharmacokinetic handling of drug by the body.

•• Apart from Chemoprophylaxis, Immunization of

the Contacts of Diphtheria patients is based on their
vaccination status. Diphtheria antitoxin vaccine is given
to contacts if their vaccination status is uncertain or
questionable.
60. Variation in drug responsiveness to a particular dose of
the drug in different individuals can be obtained from:
a. Graded Dose Response Curve
b. Efficacy
c. Potency
d. Quantal Dose Response Curve

Ans.  (d) Quantal Dose Response Curve.

Ref: Goodman & Gilman’s Pharmacological basis of
Therapeutics, 13th Ed. Pg.No: 36.

19
 Section A  Recent Questions 2019

•• Drug response to the same drug used in same doses in Emetic Condition Effective Antiemetics
a population varies based on many factors governing Chemotherapy •• 5HT3 Antagonists : Odansetron,
pharmacodynamic variability (like age, genetics, co- Induced Nausea Granisetron, Dolasetron, Tropisetron and
morbid condition, concomitant medication, etc) Vomiting (CINV) Palanosetron (5HT3 Blockers are the DOC
operant in that subset of population under study. for acute post chemotherapy induced
•• This pharmacodynamic variability in a population is nausea vomiting)
analyzed using a Quantal Dose Response Curve •• D2 Blockers: Metoclopramide (additional
•• Quantal Dose Response relationship is an “all or none” 5HT3 blockade and 5HT4 agnism),
plot traced based on response elicited to varying dose of Promethazine (additional antihistaminic
drug administered to a population. and anticholinergic action)
•• Therapeutic Index of a drug is determined based on data •• Cannabinoid receptor agonist:
plots from Quantal Dose Response Curves. Dronabinol, Nabilone
•• Median Effective Dose (ED50) is the dose of a drug •• Neurokinin Receptor Antagonist:
required to produce a specified effect in 50% of the Aprepitant (DOC for delayed onset CINV)
population. Emesis •• DOC- 5HT3 Antagonists : Odansetron,
•• In preclinical studies, the Median Lethal Dose (LD50) associated Granisetron, Dolasetron, Tropisetron and
is determined in experimental animals – the dose that with upper GI Palanosetron
produced mortality of 50% of animal group used in irradiation
testing. Postoperative •• Prochlorperazine, Promethazine, 5HT3
•• Therapeutic Index is determined as a ratio of LD50/ED50 emesis antagonists, Droperidol
– provides the safety margin of a drug. The wider the Emesis of •• Doxylamine + Pyridoxine
Lethal DRC is spaced away from the Therapeutic effect pregnancy •• Diphendydramine, Promethazine,
DRC  Drug has a wide safety margin. Cyclizine, Meclizine
61. Most specific antiemetic for Chemotherapy induced Vestibular •• H1 Antihistaminics: Cyclizine
vomiting is: sickness •• Anticholinergics: Hyoscine
a. Doxylamine b. Tegaserod
62. Identify the true statement regarding Clinical Trials
c. Granisetron d. Domperidone
a. Phase 1 is done to determine efficacy in patients
Ans.  (c) Granisetron b. Healthy volunteers are recruited for the first time in
Phase II
Ref: Goodman & Gilman’s Pharmacological basis of c. Randomized Controlled Trials in patients is done in
Therapeutics, 13th Ed. Pg.No: 935-6. Phase III
•• 5HT3 antagonists like Odansetron, Granisetron, d. Phase IV is Pharmacokinetics study in animals
Dolasetron, Tropisetron and Palanosetron are the most
specific and effective agents in the management of Ans. (c) Randomized Controlled Trials in patients is
chemotherapy-induced nausea vomiting and in nausea done in Phase III
associated with upper abdominal irradiation. Ref: Goodman & Gilman’s Pharmacological basis of
Therapeutics, 13th Ed. Pg.No: 6.

•• Phase III Clinical trials are Randomised, Controlled (either placebo or standard of care comparator), multisite and blinded
(+/-) study conducted in a large number of patient participants.
TRIAL → PHASE I PHASE II PHASE III PHASE IV
(First in Human- (First in Patient – (Multisite – Therapeutic (Post marketing
FEATURES Human Pharmacology Therapeutic exploration confirmation or surveillance or data
↓ and Safety study) and dose ranging study) comparison study) gathering study)
Sample Size 10-100 50-500 1000-5000 plus Many thousands of
participants
Inclusion criteria Healthy Volunteers Patients Patients Patients
Intervention Investigational New Drug Investigational New Drug Investigational New Drug New Drug approved for
market
Study Design Open label Randomized, Controlled, Randomized, Controlled, Open label
with or without blinding with or without blinding
Objective Safety, Tolerability Efficacy, Dose ranging Confirm efficacy in larger Adverse events, Drug-drug
population interaction, Compliance
Duration of study 1-2 years 2-3 years 3-5 years Restricted marketing and
PSUR submission for the
first 4 years after approval.
Contd…

20
 Section A  Recent Questions 2019

63. Fluoroquinolone with highest oral bioavailability: •• Gemifloxacin is a third generation fluoroquinolone
a. Levofloxacin b. Gemifloxacin having absolute oral bioavailability.
c. Ciprofloxacin d. Norfloxacin •• All third generation fluoroquinolones: Sparfloxacin,
Gatifloxacin and Gemifloxacin have 100% oral
Ans.  (b) Gemifloxacin biovailability.
Ref: HL & KK Sharma’s Principles of Pharmacology.3rd Ed. •• Among the Fluoroquinolones, Norfloxacin has the least
Pg.No: 724. oral bioavailability.

Fluoroquinolones Drugs Oral Bioavailability Spectrum

First generation: Norfloxacin Generally oral Bioavailability •• GN aerobes (E.coli, Shigella, Salmonella,
Ciprofloxacin is in range of 80-100%, Proteus),
Ofloxacin except Norfloxacin (~35%) •• GN Cocci (Neiserria),
Pefloxacin •• Bacillus anthracis (only susceptible GP bacilli),
Lomefloxacin •• Mycobacterium tuberculosis,
•• Chlamydiae and Rickettsiae.
Second generation: Levofloxacin 95-100% •• Similar to 1st generation
Prulifloxacin       +
•• More activity against:
•• GP cocci (Strep. Pneumonia),
•• Mycoplasma,
•• Legionella,
•• Chlamydia.
Third generation: Sparfloxacin Absolute oral bioavailability •• Enhanced activity against GP cocci – Strep,
Gatifloxacin (~100%) Staph & Enterococcus.
Gemifloxacin •• Mycobacterium Tuberculosis,
•• MAC,
•• Mycoplasma pneumonia.
Fourth generation: Moxifloxacin In ranges of 88-92% •• More active against GP organisms and most
Trovafloxacin active FQ against anaerobes.
Alatrofloxacin
Finafloxacin

64. Which of the following statement is true regarding Fixed

Dose Combination of drugs?
a. Adverse effect of one drug may be reduced by the other
drug
b. Two drugs with different pharmacokinetics can be
combined easily
c. Dose of one drug can be altered independently as per
requirement
d. Adverse effect can be ascribed to a single drug

Ans.  (a) Adverse effect of one drug may be reduced by

the other drug
Ref: HL & KK Sharma’s Principles of Pharmacology.3rd Ed.
Pg.No: 57-8.
•• Fixed Drug Combination (FDC): Two different drug
65. Which of the following is a K+ Channel Opener?
moieties are combined into a single pharmaceutical
a. Ranolazine b. Nicorandil
formulation.
c. Verapamil d. Lignocaine
•• As a rule, two drugs are ideal for combination into a FDC
only when they have comparable pharmacokinetics. Ans.  (b) Nicorandil
(Rules out Option b)
ƒƒ E.g.: Cotrimoxazole = Sulfamethoxazole (t1/2 -11h) + Ref: KD Tripathi’s Essentials of Medical Pharmacology. 8th
Trimethoprim(t1/2 – 10h) Ed. Pg. No:585
ƒƒ Syndopa = Levodopa (t1/2 -1.7h) + Carbidopa (t1/2 -2h)

21
 Section A  Recent Questions 2019

•• Nicorandil is a niacinamide derivative – used as a

second line anti-anginal drug – Its mechanism of action
involves opening ATP sensitive K+ channels and by
mediating nitrovasodilation.

•• Apart from the anticipated nitrates like side effect of

Headache, Nicorandil can cause serious adverse effects
involving ulceration of skin, mucous membrane, eyes
and the gastrointestinal tract. •• Methotrexate is used in dosage of 10-25mg/week oral or
•• Contraindications to Nicorandil: subcutaneous along with Folic acid 1mg/day as a part
ƒƒ Absolute C/I: of toxicity amelioration. Subcutaneous dosing is better
ŠŠ Patients with hypovolaemia, cardiogenic shock or in terms of bioavailability and pharmacodynamics
acute pulmonary edema attained.
ŠŠ Patients on Sildenafil (PDE-5 inhibitor) , Riociguat •• Recommendation Summary for use of Methotrexate in
(soluble guanylate cyclase stimulator) RA:
ƒƒ Relative C/I or Cautious use in: ƒƒ Administration of a high initial dose of Methotrexate
ŠŠ Patients with NYHA III/IV Heart Failure followed by rapid down titration to optimal dose can
ŠŠ G6PD deficiency (risk of methhemoglobinaemia) improve the response to oral Methotrexate without
ŠŠ Patients taking Dapoxetine (risk of orthostatic much compromise on patient safety or tolerability.
hypotension) ƒƒ Response to treatment following optimal oral
ŠŠ Patients with renal dysfunction and drugs causing Methotrexate takes a minimum of 3 months, and at
hyperkalemia least 6 months to monitor accurate effect on disease
66. A Rheumatoid Arthritis patient on Methotrexate, progression
Steroids and NSAIDs for past 4 months has had no ƒƒ Patients not responding or showing inadequate clinical
retardation of disease progression. What is the next response to oral Methotrexate may be “rescued” by
rational step in management? switching to subcutaneous Methotrexate.
a. Start monotherapy with anti-TNF alpha drugs ƒƒ While changing over from oral to subcutaneous
b. Continue Methotrexate and Steroids dosing of Methotrexate, the same oral dose received
c. Stop oral Methotrexate and start parenteral by patient should be matched and given, following
Methotrexate which on a later course, the dose may be altered.
d. Add Sulfasalazine ƒƒ If Methotrexate monotherapy fails to produce clinical
improvement, another agent may be considered for
Ans. (c) Stop oral Methotrexate and start parenteral combination.
Methotrexate
67. Tolvaptan is used for:
Ref: Goodman & Gilman’s Pharmacological basis of a. SIADH
Therapeutics, 13th Ed. Pg.No: 2537. b. Central DI
•• Methotrexate, a first line Disease Modifying Rheumatoid c. Von Willebrand Disease
Arthritis Drug is the first choice of drug in management d. Catecholamine resistant Shock
of early Rheumatoid Arthritis.
Ans.  (a) SIADH
•• It is the first choice conventional DMARD and an
anchor drug chosen for most Anti-Rheumatoid arthritis Ref: Goodman & Gilman’s Pharmacological basis of
combination therapies. Therapeutics, 13th Ed. Pg.No: 466.

22
 Section A  Recent Questions 2019

•• Tolvaptan is a selective Vasopressin V2 receptor •• Other Neuraminidase inhibitor recommended for the
antagonist indicated in treatment of euvolaemic or same purpose is Zanamivir – available for inhalation
hypervolaemic hyponatremia (Na+ < 125mEq/L or in patients over 5 years of age. Both these drugs are
clinically symptomatic hyponatraemia, in spite of fluid used with a risk benefit approach in pregnant women.
restrictive corrective measures), including patients with [Category C]
Syndrome of Inappropriate ADH Secretion and Heart
Failure.
•• Bartter and Schwartz criteria defines SIADH as follows:

•• Antiviral chemoprophylaxis generally is not

Drugs causing SIADH Treatment options for recommended if more than 48 hours have elapsed since
SIADH the first exposure to a person with influenza.
•• Three drug classes most •• Fluid restriction
commonly implicated to •• IV administration of Antiviral Age group Treatment Prophylaxis
induce SIADH are: hypertonic saline agent
„„ Psychotropic medication: •• Diuretics – Loop diuretics Oseltamivir Adults 75 mg twice 75 mg once
Selective Serotonin like Frusemide, Osmotic (Tamiflu) daily daily
Reuptake Inhibitors, agents like urea and
Children ≥ 1 year:
Tricyclic Antidepressants, mannitol
Haloperidol ≤ 15 kg 30 mg twice 30 mg once
•• Vasopressin antagonists
> 15-23 kg daily daily
„„ Sulphonylureas :
> 23-40 kg 45 mg twice 45 mg once
Chlorpropamide
> 40 kg daily daily
„„ Vinca alkaloids:
60 mg twice 60 mg once
Vincristine, Vinblastine
daily daily
•• Other drugs that have Drug classes used for 75 mg twice 75 mg once
strong propensity to cause treating SIADH: daily daily
drug induced SIADH are – •• By inducing Nephrogenic
Infants < 1yeara 3 mg/kg/ 3 mg/kg/dose
clonidine, cyclophosphamide, Diabetes Insipidus :
dose twice once daily
ifosphamide, methyldopa, Demeclocycline, Lithium
daily
enalapril, felbamate, •• By promoting sodium
pentamidine and vinorelbine. retention: Fludrocortisone Infants < 3monthsa 3 mg/kg/ Not
•• Vasopressin Antagonist dose twice recommended
Aquaretics: Conivaptan daily unless clinical
(nonselective parenteral), situation
Tolvaptan (V2 selective oral) judged critical
68. Mechanism of action of Oseltamivir: Zanamivir Adults 10 mg 10 mg
a. DNA polymerase inhibition (Relenza) (two 5-mg (two 5-mg
b. Inhibition of viral mRNA inhalations inhalations
c. Blocking viral uncoating twice daily) once daily)
d. Neuraminidase inhibition Children ( ≥7 years 10 mg 10 mg
for treatment, (two 5-mg (two 5-mg
Ans.  (d) Neuraminidase inhibition
≥5) years for inhalations inhalations
Ref: Goodman & Gilman Pharmacological Basis of chemoprophylaxis twice daily) once daily)
Therapeutics, 13th Ed.-Pg:963. CDC guidelines for Influenza Although not FDA approved use of oseltamivir for influenza
Chemoprophylaxis. treatment in infants aged < 14 days and for prophylaxis in infant
Available from: www.cdc.gov/h1n1flu/recommendations and 3 months to 1 year is recommended by the CDC and the
•• Oseltamivir, an orally available Neuraminidase inhibitor AAP.
is the drug recommended for treatment and post AAP: American Academy of Pediatrics
exposure chemoprophylaxis of Influenza A and B in 23
healthy adults and children. •• Contrast between Oseltamivir and Zanamivir:
 Section A  Recent Questions 2019

ƒƒ Oseltamivir can be administered immaterial of meal •• Buspirone is a 5HT1A partial agonist used as an anxiolytic.
timing. •• It is also used in relief of pain and related anxiety of
ƒƒ Oseltamivir dose titration based on creatinine functional dyspepsia associated with Irritable Bowel
clearance is needed in renal dysfunction. Syndrome.
ŠŠ For Treatment: CrCl 10-30 ml/min  75mg BD x •• Buspirone (atypical anxiolytic), in contrast to
5 days conventional Benzodiazepine anti-anxiety drugs:
ŠŠ For Chemoprophylaxis: CrCl 10-30 ml/min  ƒƒ Have minimal abuse liability
30mg OD or 75mg OD on alternate days continued ƒƒ No withdrawal reactions on abrupt discontinuation
till 10 days post exposure. ƒƒ Lesser impairment of psychomotor skills and function
ƒƒ Zanamivir is an inhaled Neuraminidase inhibitor •• ADR profile of Buspirone: tachycardia, nervousness, GI
– used without dose titration in instance of renal distress, parasthesias and dose dependent miosis.
dysfunction – because systemic absorption, 70. Carbapenem with maximum seizure risk is:
subsequently renal elimination following inhalation a. Imipenem b. Meropenem
is minimal. c. Ertapenem d. Doripenem
ƒƒ Zanamivir, being an inhaled formulation is not to be
used in patients with Chronic Obstructive Pulmonary Ans.  (a) Imipenem
Disease, Bronchial asthma.
Ref: Goodman & Gilman Pharmacological Basis of
69. Buspirone acts on: Therapeutics, 13th Ed.-Pg:1035.
a. 5HT1A b. 5HT1B
•• Imipenem is a Carbapenem group of β-Lactam antibiotic
c. 5HT2 d. 5HT3
with highest propensity to induce seizures compared to
Ans.  (a) 5HT1A the other Carbapenem congeners.
•• Seizure is noted in 1.5% patients receiving Imipenen.
Ref: Goodman & Gilman Pharmacological Basis of Seizure risk is increased in patients receiving high doses
Therapeutics, 13th Ed.-Pg:230. in the presence of renal insufficiency and CNS lesions.

Carbapenem Mechanism of action Indication Notable Characteristics

Imipenem β-Lactam group of antibiotic. Nosocomial infections esp. •• Combined with Cilastatin( renal
Cephalosporin resistant: dehydropeptidase inhibitor) to prevent
→ Carbapenems act as Pneumonia, intra-abdominal degradation and attain adequate
mechanism-based inhibitors of infections and urinary tract biovailability
the peptidase domain of PBPs infections •• Dose titration in renal insufficiency needed.
→ inhibit peptide cross-linking •• Most Seizurogenic carbapenem.
Dorepenem and related peptidase reactions •• Enhanced activity against some resistant
→ disrupted cell wall formation isolates of Pseudomonas.
→ autolysis by osmosis
Meropenem Above indications •• Spectrum: More active against Gram
General Spectrum: + negative than positive bacteria, in contrast
GN rods including Pseudomonas, Meningitis to Imipenem
Ertapenem GP bacteria and anaerobes. Community-acquired infections •• Lacks activity against Pseudomonas and
and nosocomial infections Enterococcus
without •• Longest t1/2 → once daily dose sufficient
Pseudomonas risk
Faropenem, Tebipenem – orally available Carbapenem.
Razupenem – Carbapenem under Clinical Trials

71. Cilastatin is given in combination with Imipenem •• Cilastatin is a renal dipeptidase (or dehydropeptidase)
because: enzyme inhibitor, used in conjunction with Imipenem
a. Cilastatin prevents degradation of Imipenem in kidney antibiotic to prevent degradation of Imipenem by the
b. Cilastatin increases absorption of Imipenem renal tubular dipeptidase.
c. Inhibits the enzymes that digest Imipenem in stomach •• Imipenem is a carbapenem class of β-Lactam antibiotic.
d. Reduces side effects of Imipenem. It has poor absorption following oral administration.
Given IV, the drug is rapidly catabolized by the
Ans.  (a) Cilastatin prevents degradation of Imipenem in dipeptidase enzyme expressed by the brush border cells
kidney of proximal tubules in kidney.
Ref: Goodman & Gilman Pharmacological Basis of •• Both Imipenem and Cilastatin have identical
Therapeutics, 13th Ed.-Pg:1035. pharmacokinetic profile – so ideal for combination.

24
 Section A  Recent Questions 2019

•• Following concurrent administration, Imipenem  resulting in depletion of membrane ergosterol along

degradation is blocked significantly, biovailability and with accumulation of the toxic product 14→-methyl-3,6-
duration of action is enhanced, around 70% active drug diol  leading to fungal growth arrest.
is recovered from urine (When Imipenem is used alone,
only about 5.5-42.5% of unchanged drug is recovered
from urine).
72. Mechanism of action of Triazoles:
a. Inhibits ergosterol biosynthesis
b. Inhibits tubulin
c. Inhibits glucan synthesis
d. Inhibits cell wall synthesis

Ans.  (a) Inhibits ergosterol biosynthesis

Ref: Goodman & Gilman Pharmacological Basis of
Therapeutics, 13th Ed.-Pg:1091.
•• Triazole antifungals (Fluconazole, Itraconazole,
Voriconazole, Posaconazole) inhibit14-→-sterol
demethylase  impair the biosynthesis of ergosterol

Drug Mechanism Preferred choice

ECHINOCANDINS: Inhibit synthesis of 1,3 β-glucan synthase → •• Deeply invasive Candidiasis
Caspofungin, Micafungin, inhibition of fungal cell wall synthesis •• Empirical and Prophylactic antifungal for deep
Anidulafungin mycoses in immunocompromised host.
POLYENES: Binds to fungal cell wall ergosterol and increase •• Invasive Aspergillosis
Amphotericin B, Nystatin membrane permeability •• Blastomycosis
•• Coccidiomycosis
•• Cryptococcosis
•• Rapidly progressing/ CNS/ Meningeal
Histoplasmosis
•• Mucormycosis
•• Extracutaneous Sporotrichosis
•• Empirical therapy of deep mycoses in
immunocompromised host.
ALLYLAMINE: Inhibits Sqaulene epoxidase •• Onychomycosis
Terbinafine •• Dermatophytosis
AZOLE: Inhibits the fungal cytochrome P450 enzyme •• All deep mycoses except Microsporidia and
Imidazole : Clotrimazole, ‘lanosterol 14-demethylase’ and thus impairs Pneumocystis.
Miconazole, Econazole, ergosterol synthesis
Oxiconazole, Ketoconazole

Triazole: Itraconazole,
Fluconazole, Voriconazole,
Posaconazole
5-Flucytosine Competitive inhibitor of thymidylate synthesis •• Cryptococcosis in non AIDS or early AIDS patients
→ inhibits fungal DNA synthesis
Griseofulvin Disruption of mitotic spindle and inhibition of •• Dermatophytosis
fungal mitosis. •• Onychomycosis

73. Identify the false statement regarding Teduglutide is: Ref: Goodman & Gilman Pharmacological Basis of
a. Used for Short-Bowel Syndrome Therapeutics, 13th Ed.-Pg:939
b. GLP2 agonist •• Teduglutide is a Glucagon-like peptide-2 (GLP-2)
c. A pancreatic enzyme analogue secreted by the ‘L’ cells of Ileum and Colon.
d. A gut Hormone •• GLP-2 is the only intestinotrophic gut peptide hormone.
It induces growth of intestinal mucosa by upregulating
Ans.  (c) A pancreatic enzyme
Insulin like Growth Factor 1 and thereby promotes
absorption of nutrients from the alimentary tract.
25
 Section A  Recent Questions 2019

•• Teduglutide is a 33 amino acid GLP-2 analogue •• Therapeutic Indications of Mannitol:

approved for subcutaneous use (0.05mg/Kg/day – once ƒƒ By IV route:
daily) for improving intestinal absorption of nutrients in ŠŠ Treatment of dialysis disequilibrium syndrome
Parenteral nutrition dependent Short-Bowel Syndrome ŠŠ Reduction of IOP in acute glaucoma and during
patients. periopertaive periods of ocular surgeries.
•• Pharmacokinetics: t1/2 : 1-2 hours, catabolized slowly ŠŠ To reduce intracranial tension associated with
by dipeptidyl peptidase 4 enzyme, excreted in urine. cerebral edema and CNS mass lesions.
•• ADR: Nausea, Abdominal pain, Haedache, Flu-like ŠŠ For treatment and prevention of acute kidney
symptoms. injury
•• Contraindication: Teduglutide carries a risk of cancer ŠŠ Enhance urinary excretion of Salicylates,
induction in the bowels, so should not be used in Barbiturates, Bromides and Lithium following
patients with active or risk of GI malignancies, Colonic their overdose.
polyps and Pancreatitis. ƒƒ By oral inhalation : to diagnose bronchial
74. Hypertension and pulmonary edema associated with hyperreactivity.
scorpion sting is managed by: ƒƒ Transurethral irrigation to prevent hemolysis during
a. Carvedilol b. Prazosin urological procedures.
c. Spironolactone d. Phentolamine •• Use of Mannitol is contraindicated in Congestive Cardiac
Failure, Pulmonary Edema, Renal Failure and in patients
Ans.  (b) Prazosin with active cranial bleeding.
Ref: Harrisons Principles of Internal Medicine. 20th Ed. 76. Drug inhibiting granulocyte migration is:
Pg.No: 3329 a. Montelukast b. Cromoglycate
c. Colchicine d. Felbamate
•• Prazosin, a a1 selective adrenergic antagonist is a
favorable choice for management of scorpion sting Ans.  (c) Colchicine
associated hypertension and pulmonary edema.
Ref: Goodman & Gilman Pharmacological Basis of
•• Hospitalization in emergency unit Therapeutics, 13th Ed.-Pg:702-3
•• Sedation and control of involuntary muscle •• Colchicine, an anti gout medication exerts its
movements induced by scorpion sting - pharmacological action by hindering granulocyte
monitored IV Midazolam infusion migration in gouty inflammation.
Management of •• Hypertenstion and pulmonary edema •• Colchicine is indicated in the intercritical periods for
lethal scorpion respond to Prazosin, Nifedipine, prolonged prophylaxis against acute attacks of gout.
stings Nitroprusside or Hydralazine •• Mechanism of Colchicine in Acute Gout is illustrated
•• Administration of antivenom in case of below:
severe evenomation. (FDA approved
scorpion sting antivenom from Colchicine
C.sculpturatus in horse serum)

75. Mannitol is used in the management of:

a. Congestive Cardiac Failure Arrest of G1 phase of cell cycle by binding to intracellular
b. Acute Congestive Glaucoma tubulin, thereby affecting microtubule and spindle formation
c. Acute Renal Failure
d. Pulmonary edema

Ans.  (b) Acute Congestive Glaucoma Preventing polymerization of microtubules required for
leukocyte migration into the inflamed joint.
Ref: Goodman & Gilman Pharmacological Basis of Colchicine treated neutrophils do the ‘Drunken Walk’.
Therapeutics, 13th Ed.-Pg:1267.
•• Mannitol, an osmotic diuretic is a drug preferred in
reduction of acutely raised intraocular pressure due to
Decreased neutophil recruitment in gouty joints
Acute Congestive Glaucoma.
•• Other agents used to relieve raised Intraocular
Pressure (IOP) are: Glycerin, Hypertonic saline and
Acetazolamide. Effectively blocking the downstream vicious cascade of
•• Short term management measures to decrease IOP – inflammation mediated by chemotactic factors and superoxide
needed in acute glaucoma attacks or pre/post ocular anions liberated from activated neutrophils.
surgical procedures are met by Glycerin and Mannitol.
•• In an acute attack of glaucoma, associated symptoms 77. Drug capable of causing ocular hypotension with apnoea
of nausea and emesis – deter the use of oral agents in infants is:
(like glycerin) – in such instances, IV Mannitol or a. Acetazolamide b. Latanoprost
Acetazolamide are preferred. c. Brimonidine d. Apraclonidine
26
 Section A  Recent Questions 2019

Ans.  (c) Brimonidine Ans.  (d) Cotrimoxazole

Ref: Goodman & Gilman Pharmacological Basis of Ref: Goodman & Gilman Pharmacological Basis of
Therapeutics, 13th Ed.-Pg:1260. Therapeutics, 13th Ed.-Pg:990.
•• Brimonidine, an a2 selective adrenergic agonist used •• Cotrimoxazole is the drug of choice for the above disease
in treatment of Glaucoma has propensity to cause Cyclosporiasis.
respiratory depression when used in children. •• Cyclospora cayetanensis is a coccidian parasitic
•• Brimonidine is notorious in causing CNS depression infection presenting with watery diarrhea (usually self
and apnoea in neonates. Hence, its use in children <2 limiting in immunocompetent, but problematic in
years of age is contraindicated. immunocompromised).
•• Brimonidine and Apraclonidine are Clonidine derivates •• Cotrimoxazole (Fixed drug combination of
- a2 selective adrenergic agonist – reduce intraocular Trimethoprim and Sulfamethoxazole) is the single most
pressure by decreasing aqueous production. effective treatment for Cyclosporiasis.
•• Unlike Apraclonidine, Brimonidine being lipophilic •• Trimethoprim-Sulfamethoxazole (160/800mg) twice
- can traverse the blood brain barrier and induce CNS a day for 7-10 days is adequate in immunocompetent
depression. patients.
•• Brimonidine is administered as topical eye preparation •• HIV infected patients with Cyclosporiasis require long
to reduce IOP in ocular hypertension and open angle term suppressive maintenance drug therapy to prevent
glaucoma. relapse.
•• Topical Brimonidine gel (0.33%) is also used as a once •• Ciprofloxacin is used as alternate to Cotrimoxazole in
daily treatment for persistent erythema of rosacea. patients with sulfa allergy. However, Ciprofloxacin is not
78. Identify the parasite from the accompanying microscope as efficacious as Cotrimoxazole against Cyclospora.
picture of oocysts as seen in stool sample of a patient 79. Inhalational anesthetic with highest respiratory
suffering from watery diarrhea. DOC for this parasitic irritation is:
disease is: a. Desflurane b. Nitrous Oxide
c. Sevoflurane d. Halothane

Ans.  (a) Desflurane

Ref: Goodman & Gilman Pharmacological Basis of
Therapeutics, 13th Ed.-Pg:395.
•• Desflurane, a fluorinated inhalational anesthetic agent
- is highly irritant on the tracheobronchial tree – making
it unsuitable for use as the primary anesthetic for
induction of anesthesia.
•• Among the fluorinated inhalational anaesthetics,
Desflurane and Isoflurane are respiratory irritants;
a. Paromomycin b. Metronidazole
Sevoflurane is devoid of tracheobronchial irritation.
c. Miltefosine d. Cotrimoxazole

Inhalational anesthetic with respiratory irritancy Ether >>Desflurane >Isoflurane

Inhalational anesthetic with fastest induction Desflurane, Sevoflurane and Nitrous Oxide
Inhalational anesthetic with poor muscle relaxant activity Nitrous Oxide
Inhalational anesthetic providing good muscle relaxation Ether>> Isoflurane, Desflurane, Sevoflurane
Inhalational anesthetic with good analgesic effect Nitrous Oxide
Fluorinated inhalational anesthetic preferred for induction of anesthesia (all other Sevoflurane
fluorinated congeners are used in maintenance – not as primary inducer anesthetic)
Seizurogenic inhalational anesthetic Enflurane

80. Drug used for smoking cessation Ref: Goodman & Gilman Pharmacological Basis of
a. Varenicline b. Acamprosate Therapeutics, 13th Ed.-Pg:430.
c. Nalmefene d. Gabapentin •• Varenicline - partial agonist at a3β4, a4β2 & a6β2
subtypes of nAChRs and agonist at a7 nicotinic Acetyl
Ans.  (a) Varenicline
Choline Receptors. Block rewarding properties of
nicotine, alcohol and drugs of abuse.

27
 Section A  Recent Questions 2019

Agents used for Mechanism Some notable characteristics

smoking cessation
Nicotine •• Slow, steady (non-spiking) maintenance •• First line pharmacological management in smoking cessation.
Replacement of small concentrations of nicotine in •• Available as chewing gum, transdermal patches, inhalators,
Therapy smokers causes reduced withdrawal nasal sprays, sublingual tablets, and lozenges.
symptoms and betters the person’s •• Ideally needs to be given for 3 months and then tapered off.
behavioral control in resisting smoking.
Bupropion •• Atypical antidepressant that blocks •• First line alternative to Nicotine Replacement Therapy.
uptake of Noradrenaline and Dopamine •• ADR: nausea, dry mouth, insomnia and agitation
-may act by augmenting dopamine •• Contraindicated in bipolar illness, eating disorders and
reward function. seizures.
Nortriptyline •• Tricyclic antidepressant •• Useful in management patients who are intolerant or relapse
following Nicotine Replacement Therapy.
Mecamylamine •• Competitive Ganglion Blocker •• Mecamylamine is used either alone or in combination with
nicotine replacement patch - to block the reward effect of
nicotine and improve abstinence rates.
Varenicline •• partial agonistic action at a4β2 •• Initial dose of 0.25 mg BD, gradually increased up to 1 mg
subtype (dense distribution in nucleus BD as per requirement for a period not more than 12 weeks;
accumbens and mesolimbic pathway) gradually tapered off.
of nAChRs → block rewarding •• ADR: mood changes, irrational behaviour, appetite & taste
properties of nicotine disturbances, insomnia and agitation.
•• BoxWarning:Drug induced suicidality (+)

81. Indication for use of Pegylated Filgrastim is in the •• ADR: mild to moderate bone pain, local skin reactions
correction of due to subcutaneous/IV administration, cutaneous
a. Anaemia b. Neutropenia necrotizing vasculitis (rare).
c. Thrombocytopenia d. Pancytopenia •• Contraindication: Patients with known allergy to E.coli
protein, Sickle Cell Anemia.
Ans.  (b) Neutropenia
82. Agent used for eliciting diagnostic differentiation of
Ref: Goodman & Gilman Pharmacological Basis of Myasthenia Gravis from Cholinergic crisis is:
Therapeutics, 13th Ed.-Pg:756. a. Ecothiophate b. Edrophonium
•• Pegylated Filgrastim is a long acting Recombinant c. Neostigmine d. Ambenonium
human Granulocyte Colony Stimulating Factor – used in
Ans.  (b) Edrophonium
treatment of Neutropenia.
•• Filgrastim is a glycoprotein of 175 amino acids. Long Ref: Goodman & Gilman Pharmacological Basis of
acting forms of Filgrastim providing extended duration Therapeutics, 13th Ed.-Pg:172.
of action are PegFilgrastim and LipeFilgrastim. •• Edrophonium test is used to distinguish between
•• Route of administration: Subcutaneous injection / Myasthenic crisis of autoimmune Myasthenia Gravis
Intravenous infusion and Cholinergic crisis.
•• Indications of Filgrastim – In treatment of Neutropenia •• Edrophonium is a short acting reversible non-carbamate
associated with: Acetylcholinesterase inhibitor (indirectly acting
ƒƒ Post autologous hematopoietic stem cell transplant cholinomimetic).
ƒƒ High dose cancer chemotherapy •• It is based on the scientific rationale that muscular
ƒƒ Congenital neutropenias and neutropenic weakness of myasthenic crisis (caused by inadequate
myelodysplasia cholinergic stimulation) dramatically improves on
ƒƒ HAART therapy administration of Edrophonium.
ƒƒ Prior to Peripheral Blood Stem Cell collection •• In Cholinergic crisis - caused by overtreatment with
(Filgrastim promotes CD34 progenitercells in anticholinesterases resulting in muscle weakness
marrow, reducing number of collections required for by induction of persistent depolarization, further
transplant) administration of Edrophonium causes drastic
worsening of muscle weakness.

28
 Section A  Recent Questions 2019

84. Which IV anesthetic does not cause cardiac depression?

a. Etomidate
b. Ketamine
c. Methohexital
d. Thiopentone

Ans.  (a) Etomidate.

Ref: Goodman & Gilman Pharmacological Basis of
Therapeutics, 13th Ed.-Pg:391.
•• Cardiovascular stability after induction is a major
advantage of Etomidate in contrast to Propofol or
Barbiturates.
•• Induction doses of Etomidate typically produces: no
change/small increase in heart rate; little or no decrease
in blood pressure or cardiac output. Etomidate has little
effect on coronary perfusion pressure while reducing
83. Anesthetic not painful on Intravenous administration is: myocardial O2 consumption.
a. Ketamine b. Propofol •• It is a preferred choice of induction anesthetic in patients
c. Etomidate d. Methohexital
prone to hypotenstion or with low cardiac reserve.
Ans.  (a) Ketamine 85. Mechanism of action of curare like drugs:
a. Competitive, Non depolarizing block at the Nm
Ref: Goodman & Gilman Pharmacological Basis of cholinergic receptors
Therapeutics, 13th Ed.-Pg:391. b. Noncompetitive, Non depolarizing block at the Nm
•• Ketamine on intravenous administration is absolutely cholinergic receptors
devoid of pain at injection site. c. Competitive, Depolarizing block at the Nm cholinergic
•• Ketamine is a NMDA antagonist intravenous general receptors
anesthetic agent – that induces a characteristic cataleptic d. Noncompetitive, Depolarizing block at the Nm
state called “Dissociative Anesthesia” – a state of induced cholinergic receptors
dissociation from onself and surrounding.
•• Dissociative anesthesia is due to selective interruption of Ans.  (a) Competitive, Non depolarizing block at the Nm
association pathways in the neocortex and thalamus  cholinergic receptors
characteristic somato-sensory blockade, a combination Ref: KD Tripathi.Essentials of Medical Pharmacology. 8th
of Catalepsy +Catatonia+ Analgesia+ Amnesia (without Ed. Pg.374
complete loss of consciousness like other general
•• Curare like drugs are Competitive, Nondepolarizing
anesthetics)
blockers at the NM Cholinergic Sodium channels at the
neuro-muscular junction  skeletal muscle relaxation.
•• Non depolarizing agents are bulky molecules (
Pachycurare) – that have affinity for NM receptors but
lack intrinsic activity.
•• Their skeletal muscle blockade is antagonized by
Neostigmine

29
 Section A  Recent Questions 2019

•• Lignocaine is the drug of choice for Digoxin induced

Comparison between Competitive and Depolarising
Ventricular Tachycardia.
Skeletal Muscle Relaxants.
•• Digoxin, a cardiac glycoside – used in treatment of
Characteristics Competitive Depolarising heart failure and in control of ventricular rate in atrial
Skeletal Muscle Skeletal Muscle fibrillation/flutter.
Relaxant Relaxant •• It has low margin of safety and high toxicity index.
Drugs Curare drugs Succinylcholine, (Therapeutic Index: 1.5-3).
Decamethonium •• About 25% of patients on Digoxin therapy develop
toxicity features.
Type of relaxation Flaccid paralysis Fasciculation followed
by flaccid paralysis
Neostigmine Antagonises block No reversal
Histamine ++ Negligible
releaser
Sequence of Fingers, eyes → Neck, limbs → Face,
blockade limbs → neck, Jaw, eyes, pharynx →
face → trunk → trunk → respiratory
respiratory muscles muscles
Pharmacogenetic - Pseudocholinesterase
variation deficiency →
Succinylcholine
apnoea

86. Reason for preferring cis-Atracurium over Atracurium

is:
a. Equal potency like Atracurium
b. Lesser provocation of histamine release
c. Short fast action
d. Does not undergo Hoffman elimination

Ans.  (b) Lesser provocation of histamine release

•• Digoxin toxicity can induce almost any cardiac
Ref: Goodman & Gilman Pharmacological Basis of dysrrhythmia except rapidly conducted atrial
Therapeutics, 13th Ed.-Pg:188. arrhythmias like atrial flutter and atrial fibrillation.
•• Cis-Atracurium is a R enantiomer of Atracurium that Mobitz type II AV block is also a rare phenomenon
does not provoke histamine release. in digoxin toxicity. Second-degree AV block (Type 2)
•• Compared to Atracurium, Cis-Atracurium is: is usually caused by structural damage to the distal
ƒƒ 4 times more potent conduction system located in the ventricular portion
ƒƒ Slow in onset of action, but similar duration of action of the myocardium- linked to an infarction/idiopathic
ƒƒ Not hydrolysed by plasma cholinesterase and has fibrosis/cardiac surgery/ infections/ inflammations/
limited hepatic metabolism  less amount of toxic auto-immune disease. 
metabolites are formed. (Cis-Atra also undergoes •• Digoxin- specific Fab antibody is a specific antidote for
Hoffman elimination) Digoxin Overdosage. (~40mg of Fab = 1mg Digoxin ).
ƒƒ Does not provoke histamine release, lesser side effects 88. Contraindications to use of Beta Blockers:
ƒƒ Cis-Atracurium is preferred skeletal muscle relaxant a. Glaucoma b. Tachycardia
in elderly patients and for patients with liver/kidney c. Bronchial asthma d. Hypertension
disease.
87. Drug of Choice for Digoxin induced Ventricular Ans.  (c) Bronchial Asthma
Tachycardia: Ref: Sharma’s Principles of Pharmacology.3rd Ed. Pg. No:
a. Propranolol b. Diltiazem 191-2.
c. Verapamil d. Lignocaine
•• Bronchial asthma is an absolute contraindication of non
Ans.  (d) Lignocaine selective β Blockers – as they induce bronchoconstriction
by knocking off β2 mediated adrenergic bronchodilation.
Ref: KD Tripathi.Essentials of Medical Pharmacology. 8th
Ed. Pg:560

30
 Section A  Recent Questions 2019

Platelet Aggregometry:
Absolute Relative Contraindication
Contraindication
•• Symptomatic •• Psoriasis
Bradycardia, Sick •• Peripheral Artery Disease and
Sinus Syndrome, Raynaud phenomenon
Heart Blocks •• Pregnancy (Atenolol is absolutely
greater than first contraindicated)
degree, A-V Blocks •• Concurrent use of β Blockers with the
•• Cardiogenic shock, following drugs is not recommended
Hyotension „„ Calcium Channel Blockers →
•• Decompensated added cardiac depression
Heart Failure „„ Insulin and Oral Hypoglycaemic
•• Bronchial Asthma drugs → β Blockers mask the
hypoglycemic adrenergic driven •• In the image shown above, agglutination is seen with the
symptoms – hypoglycemia attacks ristocetin. There is no aggregation with ADP, adrenaline
may go unnoticed. or collagen. 
•• Possible diagnosis: Glanzmann’s thrombasthenia or
afibrinogenaemia
PATHOLOGY
89. Vitamin A is stored in
a. Hepatocyte
b. Ito cell
c. Hepatic endothelial cell
d. Kupffer cell

Ans.  (b) Ito cell

Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 327
•• Kupffer cell is a part of mononuclear phagocyte system
•• Reserves of Vitamin A are stored in the perisinusoidal
•• In the image above, there is lack of agglutination with
stellate cells (ITO cells) in the liver
ristocetin, but agglutination occurs with other agonists.
•• Deficiency of vitamin A can cause SQUAMOUS
•• Possible diagnosis: Von Willebrand Disease (vWD) or
METAPLASIA
Bernard Soulier Syndrome (BSS).
90. Glanzmann thrombasthenia is due to defect in •• vWD is differentiated from BSS by repeating the platelet
a. Gp IIb/IIIa aggregometry after adding cryoprecipitate.
b. Gp Ib-IX •• After adding cryoprecipitate (which contains von
c. CD68 Willebrand factor), agglutination occurs with ristocetin.
d. Von Willebrand factor Then a diagnosis of vWD can be made.
•• BSS – Disorder of platelet adhesion, due to defect in Ib-
Ans.  (a) Gp IIb/IIIa
IX receptor
Ref: Robbins Basic Pathology, 9th Edition, Pg.no: 660 •• Glanzmann thrombasthenia – Disorder of platelet
aggregatation, due to defect in IIb-IIIa receptor.
Platelet Function Defects:
•• Glanzmann’s thrombasthenia (GT) is an autosomal
•• Defect in platelet adhesion - Bernard Soulier syndrome, recessive inherited platelet function defect characterized
Von Willebrand’s disease by normal platelet count, prolonged bleeding time and
•• Defect in platelet aggregation - Glanzmann abnormal clot retraction.
thrombasthenia, Afbrinogenemia •• Clot retraction test is a measurement of platelet function.
•• Defect in platelet secretion - Storage pool disorders, Clot retraction test is abnormal in thrombocytopenia,
drugs (NSAID) induced thrombasthenia and polycythemia
Glanzmann thrombasthenia is due to defective platelet
aggregation, due to defect in receptor Gp IIb-IIIa 91. Which of the following is an antiapoptotic gene?
a. Bcl2 b. Bcl – XL
Bernard Soulier syndrome is due to defective platelet
c. BAX d. Both a & b
adhesion due to defect in Gp Ib-IX
Ans.  (d) Both a&b
Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 38&39

31
 Section A  Recent Questions 2019

•• BCL12, BCL XL and MCL are antiapoptotic genes 94. Fish mouth stenosis in Rheumatic heart disease is due to
•• BAX and BAK are proapoptotic genes a. Calcification and fibrosis bridging across valvular
•• BAD, BID, BIM,Puma and Noxa are sensors of cellular commissures
stress and damage. b. Fibrinoid necrosis
•• Also called BH3 only proteins. As they contain only third c. Both a & b
of the four BH domains d. None of the above
92. Which of the following is true about alpha 1 antitrypsin?
Ans. (a) Calcification and fibrosis bridging across
a. Inhibits elastase
b. Inhibits trypsinogen activation in pancreas valvular commissures
c. Inhibits trypsin activating protease Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 425
d. Inhibits chymotrypsin
Morphology of Rheumatic Heart Disease
Ans.  (a) Inhibits elastase •• ASCHOFF BODIES– Pathognomic of Rheumatic fever
•• Aschoff bodies consists of foci of T lymphocytes,
Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 658&659
few plasma cells and plump activated macrophages
•• a1 antitrypsin deficiency is an Autosomal recessive (ANITSCHOW CELLS)
disorder •• Macrophages have round to ovoid nuclei, chromatin
•• It is synthesised in the liver condenses into slender wavy ribbon (CATERPILLAR
•• Deficiecy of a1 antitrypsin can cause panacinar CELLS) and abundant cytoplasm.
emphysema and can affect the liver. MAC CALLUM PLAQUES: Irregular thickening in left
•• Normal (wild) genotype of PiMM atrium
•• a1 antitrypsin deficiency can cause globular cytoplasmic
95. Which of the following is positive in Follicular
inclusions in hepatocytes
lymphoma?
•• These inclusions are PAS positive and diastase resistant
a. Bcl2 b. Bcl 6
c. Bcl 1 d. None of the above

Ans.  (a) Bcl2

Ref: Robbins Basic Pathology, 9th Edition, Pg.no: 468&469
•• Burkitt lymphoma and Follicular lymphoma arises from
Germinal center B cell
•• Mantle cell lymphoma arises from Naive B cell
•• Hairy cell leukemia and extranodal marginal zone
lymphoma arises from Memory B cell
Translocation In
•• Burkitt lymphoma t (8:14)
•• Follicular lymphoma t (14:18)
93. Which of the following is autosomal recessive disorder? •• Mantle zone lymphoma t(11:14)
a. Huntington’s chorea b. Neurofibromatosis 1 •• Marginal Zone lymphoma t(11:18)
c. Marfan’s syndrome d. Cystic fibrosis CD23 is negative in Mantle cell lymphoma
Ans.  (d) Cystic fibrosis 96. Which of the following is a cause of intravascular
hemolysis?
Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 246 a. PNH
Most of the enzyme deficiencies are Autosomal recessive b. Warm type autoimmune hemolytic anaemia
Characteristics of Autosomal Recessive Disorders: c. Cold agglutinin disease
d. Both b&c
•• Complete penetrance is common
•• Usually manifests early in age Ans.  (a) PNH
•• Affected individual can have unaffected parents
•• Siblings have one in four chance of having the trait Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 642-
643 Essentials of haematology, Kawthalkar, 2nd Edition,
Autosomal Dominant Autosomal Recessive Pg.no:199&200
Disorders Disorders •• Paroxysmal nocturnal hemoglobinura (PNH ) is an
Huntington’s disease Cystic fibrosis acquired intrinsic defect in RBC membrane
•• Its due to mutation in PIGA gene (phosphatidyl inositol
Neurofibromatosis Phenylketonuria
glycan complementation group A)
Myotonic Dystrophy Wilson’s disease •• PNH red cell are deficient in
Hereditary spherocytosis Sickle cell anaemia ƒƒ CD55 or decay accelerating f actor
ƒƒ CD 59 or membrane inhibitor of reactive lysis
Achondroplasia Friedreich ataxia
ƒƒ C8 binding protein
Osteogenesis imperfecta Spinal muscular atrophy
32 •• Characterised by pancytopenia, hemolysis and thrombosis
 Section A  Recent Questions 2019

•• Diagnosed by FLOWCYTOMETRIC ANALYSIS Fibrinoid Necrosis:

•• Thrombosis is the leading cause of disease related death •• Can occur in vasculitis.
Autoimmunehemolytic Anaemia: •• Fibrinoid necrosis can be seen in Polyarteritis nodosa,
Warm antibody type : Aschoff bodies and Malignant hypertension.
•• Common form of immunohemolytic anaemia •• Fibrinoid necrosis can be highlighted by Martius
•• Due to IgG antibodies Scarlet Blue (MSB)
•• They cause extravascular hemolysis
Cold agglutinin type:
•• Due to IgM antibodies
•• Target antigen in cold agglutinin disease is I,i
•• Associated with infection by Mycoplasma pneumoniae
Paroxysmal cold hemoglobiniuria:
•• IgG antibodies
•• Target antigen is P antigen
•• DONATH LANDSTEINER ANTIBODY: Biphasic
antibody.
•• If patients serum (containing IgG antibodies and
complement) is incubated with normal red cells in Caseous Necrosis:
cold (4 degree Celsius), IgG autoantibodies bind to •• Characterized by cheese like areas of necrosis
red cells and cause hemolyis of coated red cells when •• Seen in Tuberculosis.
temperature is raised to 37 degree Celsius.
•• IgG autoantibody in PCH is called Biphasic hemolysin
because of this property
97. Which of the following type of necrosis is seen in blood
vessel?
a. Coagulative necrosis b. Liquefactive necrosis
c. Fibrinoid necrosis d. Caseous necrosis

Ans.  (c) Fibrinoid necrosis

Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 36-37
Coagulative Necrosis:
•• Architecture of dead tissue is preserved.
•• Localised area of coagulative necrosis is called INFARCT. 98. Which of the following is/are is endogenous pyrogen?
a. IL1 b. TNF
c. Lipopolysaccharride d. Both a&b

Ans.  (d) Both a&b

Ref: Robbins Basic Pathology, 10th Edition, Pg.no: 86-87
•• Fever is a systemic effect of inflammation
•• Substances that induce fever are called pyrogens
•• Lipopolysacharide is exogenous pyrogen
•• IL1 and TNF are endogenous pyrogens
99. IL-1 is activated by
a. Caspase 1 b. Caspase 3
c. Caspase 5 d. Caspase 8
Liquefactive Necrosis:
•• Hypoxic death of cells within CNS (Central nervous Ans.  (a) Caspase 1
system) is called liquefactive necrosis. Ref: Robbins Basic Pathology, 9th Edition, Pg.no: 59. 86, 188
•• Pyroptosis is associated with release of cytokine IL 1
•• Microbial products that enter the cytoplasm of
the cell are recognised by cytoplasmic immune
receptors and activates a multiprotein complex called
INFLAMMASOME
•• Inflammasome will activate CASPASE 1 (also called
Interleukin 1β converting enzyme) and releases the
active form of IL 1
•• Several NORs (NOD like receptor) signal via
INFLAMMASOME
33
 Section A  Recent Questions 2019

•• Gain of function in NLR can cause periodic fever •• The Fingerprint patterns are not inherited and paternity
syndromes called AUTOINFLAMMATORY SYNDROMES cannot be proved through fingerprint patterns.
•• They respond to IL-1 antagonists •• The fingerprint patterns are distinctive and permanent
•• IL 1 activates fibroblasts to synthesize collagen and in individuals.
stimulates the proliferation of mesenchymal cells 103. A circular bullet wound, erythema seen around the
•• IL 1 also stimulates Th17 responses margin, blackening & tattooing present. What is the
•• Initiator caspase in Intrinsic pathway of apoptosis - IL 9 range?
•• Initiator caspase in Entrinsic pathway of apoptosis - IL a. Contact shot entry wound
8, 10 b. Close shot entry wound
•• Executioner caspase of apoptosis IL 3 & IL 7 c. Close shot exit wound
d. Near shot entry wound

FORENSIC MEDICINE Ans.  (b) Close shot entry wound

Ref: Essentials of Forensic medicine, Dr KS narayana Reddy,
100. Rigor mortis first seen in
33th Edition, P: 216
a. Eyelids b. Heart
c. Limbs d. Neck •• Presence of erythema, blackening & tattooing around
the wound indicates that it is close shot.
Ans.  (b) Heart 104. Gastric lavage is contraindicated in all the following
Ref: Essentials of Forensic medicine, Dr KS narayana Reddy, poisonings except
33th Edition, P: a. Phenol b. Sulphuric acid
c. Kerosene d. Nitric acid
The Order of Appearance of Rigor:
•• All muscles of the body, both voluntary and involuntary Ans.  (a) Phenol
are affected. Ref: Essentials of Forensic medicine, Dr KS narayana Reddy,
•• But it does not start in all muscles simultaneously 33th Edition, P: 516.
(Nysten’s rule):
Contraindications of Gastric Lavage:
•• It first appears _in involuntary muscles; the myocardium
The only absolute contraindication is corrosive poisoning
becomes rigid in an hour.
(except carbolic acid), owing to the danger of perforation.
•• Then it develops in eyelids, neck and lower jaw and passes
Gastric lavage can be done with proper precautions.
upwards to the muscles of the face, and downwards to
•• Convulsant poisons
the muscles of the chest, upper limbs, abdomen and
•• Comatose patients
lower limbs and lastly in the fingers and toes.
•• Volatile poisons, which may be inhaled.
101. Punishment of Perjury is given by •• Oesophageal varices.
a. 191 IPC b. 193 IPC •• In patients with marked hypothermia, and haemorrhagic
c. 197 IPC d. 198 IPC diathesis
Ans.  (b) 193 IPC 105. Which of the following is not used as a preservative in
chemical analysis
Ref: Essentials of Forensic medicine, Dr KS narayana Reddy, a. Glycerine b. Formalin
33th Edition, P: 13 c. Rectified spirit d. Salt solution
•• Sec 191 IPC Giving false evidence under oath (perjury
definition) Ans.  (b) Formalin
•• Sec 192 IPC Fabricating false evidence Ref: Essentials of Forensic medicine, Dr KS narayana Reddy,
•• Sec 193 IPCQ Punishment for perjury (3–7 years) 33th Edition, P: 124
102. Identical twins can be differentiated by Formalin is not usedQ as preservative for chemical analysis
a. Finger print b. DNA fingerprinting because extraction of poison becomes difficult.
c. Blood grouping d. Age
Preservatives:
Ans.  (a) Finger print •• Saturated sodium chloride solution
•• Rectified spirit
Ref: Essentials of Forensic medicine, Dr KS narayana Reddy,
•• Ten. mg./ml of sodium or potassium fluoride for blood,
33th Edition, P: 86.
urine, CSF
•• Among twins, the DNA fingerprint will show same •• Glycerol is used for virological study.
pattern
106. Fear of darkness is called
•• But the fingerprint pattern is different even in identical
a. Nyctophobia b. Mysophohbia
twins.
c. Claustrophobia d. Agarophobia

34
 Section A  Recent Questions 2019

Ans.  (a) Nyctophobia 109. A 9 years old child presented to OPD with complaints of
high grade fever, vomiting, one episode of seizure. CSF
Ref: Essentials of Forensic medicine, Dr KS narayana Reddy,
examination was done and Gram staining of the culture
33th Edition, P: 482
showed the following finding. What is the probable
•• Acrophobia is morbid fear of high places. causative agent?
•• Agarophobia is fear of being in a large open space.
•• Nyctophobia is morbid fear of darkness.
•• Claustrophobia is fear of staying in a closed or confined
space.
•• Mysophobia is morbid fear of filth or contamination.
•• Xenophobia is fear of strangers.
107. True regarding battered baby syndrome:
a. Stab injury
b. Multiple injuries at different ages
c. Fracture of long bone shafts
d. Skull bone fracture

Ans.  (b) Multiple injuries at different ages

a. Haemophilus influenzae
Ref: The essentials of forensic medicine and toxicology; Dr.
b. Neisseria meningitidis
KS Narayana Reddy, 33rd edition; Page no: 445
c. Streptococcus pneumoniae
Important Clinical Features of Battered Baby Syndrome d. Escherichia coli
•• Fractures and injuries will be at different stages of
Ans.  (c) Streptococcus pneumoniae
healing
•• Most characteristic lesion-laceration of mucosa inside Ref: Ananthanarayan and Paniker T.B of microbiology – 10th
the upper lip and often tear of frenulum noted ed – page 225
•• Infantile whiplash syndrome- shaking a child causes •• Gram staining clearly shows Gram positive cocci
subdural hematoma and intra ocular bleeding (violet/purple coloured) in pairs – classical image of
Streptococcus pneumoniae or pneumococci
•• Clinical features also helpful to confirm the diagnosis
MICROBIOLOGY •• Infections caused by Pneumococcus:
ƒƒ Pneumonia
108. True about Congenital Rubella syndrome is: ƒƒ Meningitis
a. It will become a chronic infection ƒƒ Otitis media
b. Virus can be isolated only upto 6months after birth ƒƒ Bacteremia
c. Triad of CRS are cataract, cardiac defects, cerebral palsy ƒƒ Septic arthritis
d. Infection is most serious after five months of pregnancy •• It is the most important cause of infections in
splenectomy patients, chronic alcoholics, sickle cell
Ans.  (a) It will become a chronic infection
anaemia patients.
Ref: Jawetz TB of medical microbiology – 27th edition – page 110. HIV patient presented with diarrhea. On stool
597 examination, following acid fast organisms was seen.
•• Rubella infection gets transmitted by vertical What is the drug of choice in this patient?
transmission and birth defects is more common when
acquired during first trimester of pregnancy.
•• Birth defects are uncommon when infection is acquired
after 20 weeks of gestation.
•• Congenital Rubella syndrome leads to cardiac
defects, cataract and deafness; (Classical triad).
Other manifestations are hepatosplenomegaly,
thrombocytopenic purpura, myocarditis and bone
lesions.
•• Intrauterine infection of Rubella is associated with
chronic persistence of disease.
•• Viral detection can be done in all fluids and it is excreted
upto 12-18 months of age.

a. TMP-SMX b. Nitazoxanide
c. Primaquine d. Niclosamide

35
 Section A  Recent Questions 2019

Ans.  (b) Nitazoxanide 113. A person working in an abattoir presented with

malignant pustule on hand; What is the causative agent?
Ref: T.B of medical parasitology – S.C.Parija – 4 edition –
th
a. Clostridium botulinum b. Clostridium perfringens
page 151
c. Bacillus anthracis d. Streptococcus pyogenes
•• HIV patient with diarrhea showing acid fast organisms
shows that organism may be: Ans.  (c) Bacillus anthracis
ƒƒ Cryptosporidium parvum
Ref: Ananthanarayan and Paniker’s Textbook of
ƒƒ Isospora belli
Microbiology – 10th ed – Page 250
ƒƒ Cyclospora cayetanensis
•• Image shows 4-5um sized oocysts – suggestive of •• Clinical clue here are: Abattoir who has contact with
Cryptosporidium animal products;
•• Classical malignant pustule is seen in Anthrax. It occurs
Acid fast oocysts Treatment of choice usually in face and neck
•• A papule is seen at the site of entry followed by vesicle
Cryptosporidium parvum In AIDS patients: Nitazoxanide
and necrotic ulcer.
Others: Paromomycin and Spiramycin
•• The lesion characteristic of cutaneous anthrax is central
Isospora belli TMP-SMX black eschar; This lesion is called as malignant pustule
Cyclospora cayetanensis Self limiting ; severe cases – TMP-
SMX

111. Diagnostic method of choice for leptospirosis:

a. Cold agglutination test b. MSAT
c. MAT d. Latex agglutination test

Ans.  (c ) MAT
Ref: Harrisons T.B of internal medicine - 19th edition – page
1144
•• A definitive diagnosis of leptospirosis is based on:
ƒƒ Isolation of the organism from the patient or
ƒƒ A positive result in the polymerase chain reaction
(PCR) or
Fig.  Central black eschar in cutaneous anthrax
ƒƒ Seroconversion or a rise in antibody titer. (MAT)
(Courtesy: CDC/ F. Marc LaForce, MD)
•• In cases with strong clinical evidence of infection, a
single antibody titer of 1:200–1:800 (depending on 114. Ideal dose of Diptheria antitoxin given for treatment is:
whether the case occurs in a low- or high-endemic area) a. 10,000 to 1,00,000 units b. 20,000 to 1,00,000 units
in the microscopic agglutination test (MAT) is required. c. 10,000 to 2,00,000 units d. 20,000 to 2,00,000 units
112. Investigation of choice for neurosyphilis:
a. VDRL b. FTA-ABS Ans.  (b) 20,000 to 1,00,000 units
c. RPR d. TPI Ref: Ananthanarayan and Paniker’s Textbook of
Microbiology – 10th ed – Page 245
Ans.  (a) VDRL
•• Specific treatment of diphtheria consists of antitoxic and
Ref: Harrisons T.B of internal medicine - 19th edition – page antibiotic therapy.
1136 •• Antitoxin should be given immediately when diphtheria
•• Sample of diagnosis for neurosyphilis is CSF is suspected, as the fatality rate increases with delay in
•• Only tests that can be done for neurosyphilis are: starting antitoxic treatment.
ƒƒ VDRL •• Antibiotic treatment only supplements and does not
ƒƒ FTA-ABS replace antitoxic therapy.
•• The diagnosis of asymptomatic neurosyphilis is made in •• Diphtheria antitoxin should be given in respiratory
patients who lack neurologic symptoms and signs but diphtheria – 20,000 to 1,00,000 units
who have CSF abnormalities including mononuclear 115. Infection that causes acute febrile illness with jaundice
pleocytosis, increased protein concentrations, or CSF and conjunctivitis is:
reactivity in the VDRL test. a. Malaria b. Leptospirosis
•• When VDRL is negative, FTA-ABS is done to confirm the c. Pertussis d. Typhoid
test.
•• Ideally both tests here are used in diagnosis; But when Ans.  (b) leptospirosis
you have to choose single best option – best is VDRL Ref: Harrisons T.B of internal medicine - 19th edition – page
according to CDC site and Mandells ID book. 1143

36
 Section A  Recent Questions 2019

Differential Diagnosis for Acute Febrile Illness Are: 119. A 5 years old child presented to the OPD with complaints
of rectal prolapse; On examination stunting and growth
Infections Classical symptoms
retardation was documented; What is the parasitological
Dengue Fever + Arthralgia + Rash cause for this clinical feature?
Malaria Intermittent fever + Splenomegaly + chills a. Trichuris trichiura b. Trichinella spiralis
c. Giardia lamblia d. Enterobius vermicularis
Chikungunya Fever + Arthralgia
Leptospirosis Fever + Jaundice + Conjunctivitis Ans.  (a) Trichuris trichiura
Scrub typhus Fever + Eschar Ref: T.B of medical parasitology – S.C.Parija – 4th edition –
Enteric fever Fever + Splenomegaly page 265
•• Clinical features of rectal prolapse is a direct clue for
116. A neonate was found to have cataract, deafness and diagnosis: Trichuriasis
cardiac defects. Which group of viruses does the mother •• This Infection is acquired by ingestion of soil with
was infected with: embryonated eggs (has rhabditiform larvae)
a. Togaviridae b. Flaviviridae •• It usually affects children and remains asymptomatic
c. Bunyaviridae d. Arenaviridae •• Heavy infection causes rectal prolapse in children;
appendicitis;
Ans.  (a) Togaviridae
•• Lab diagnosis: Demonstration of barrel shaped eggs
Ref: Jawetz TB of medical microbiology – 27th edition – page with mucous plugs in feces
597
•• Congenital Rubella syndrome leads to cardiac
defects, cataract and deafness; (Classical triad).
Other manifestations are hepatosplenomegaly,
thrombocytopenic purpura, myocarditis and bone
lesions.
•• Rubella belongs to Togaviridae
117. Which vaccine is contraindicated in pregnancy?
a. Hepatitis A b. Hepatitis B
c. Rabies d. Chicken pox

Ans.  (d) Chicken pox Fig.  Egg of Trichuris trichiura Courtesy: CDC/B.G. Partin
Ref: Harrisons T.B of internal medicine - 19th edition – page 120. Flask shaped ulcers seen in a dysentry patient is
1143 diagnostic of:
•• All live attenuated vaccines are contraindicated in a. Shigellosis b. Amoebiasis
pregnancy. c. Giardiasis d. Typhoid
•• Examples for live attenuated vaccines are:
ƒƒ OPV Ans.  (b) Amoebiasis
ƒƒ Yellow fever vaccine Ref: T.B of Medical Parasitology–S.C.Parija–4th edition–Page
ƒƒ Varicella zoster vaccine 33
ƒƒ MMR
•• Clinical features of amoebiasis are:
ƒƒ Influenza (attenuated vaccine)
ƒƒ Intestinal amoebiasis – characteristic flask shaped
118. Which vaccine strain is changed every yearly? ulcers
a. Influenza b. Rabies ƒƒ Amoebic liver abscess – Anchovy sauce pus
c. Hepatitis d. Ebola ƒƒ Lung abscess
ƒƒ Brain abscess
Ans.  (a) Influenza
121. A 35 years old man presented with dry cough and rusty
Ref: Harrisons T.B of internal medicine - 19th edition – page coloured sputum; He has history of eating in chinese
1209 restraunt very often with consumption of crabs often;
•• Influenza virus has two important antigens: What is the probable causative agent in this condition?
Haemagglutinin (H) and Neuraminidase (N) a. Diphyllobothrium latum
•• These antigens undergo periodic antigenic variations b. Pneumocystis jirovecii
•• Major antigens variations are seen only with influenza A c. Paragonimus westermani
viruses and may be associated with pandemics – called d. Strongyloides stercoralis
as antigenic shifts.
•• Minor variations causing outbreaks are called as Ans.  (C) Paragonimus westermani
antigenic drifts. Ref: T.B of Medical Parasitology–S.C.Parija–4th edition–Page
•• Because of these variations, vaccines should be modified 235
according to the current prevalent strain.
37
 Section A  Recent Questions 2019

•• A patient with history of crab eating and respiratory 126. Contact isolation is done for:
symptoms gives clinical clue for Paragonimus a. Mumps b. MRSA
westermani infection c. Diphtheria d. Typhoid
•• First intermediate host–Snails
•• Second intermediate host–Fresh water crab or crayfish Ans.  (c) Diphtheria
•• Infective form–Metacercariae Ref: Greenwood – medical microbiology – 18th ed – page 202
•• It causes paragonimiasis in pulmonary system; it causes
•• Strict isolation is must for patient diagnosed with
a granulomatous reaction that leads to blood mixed
diphtheria.
sputum–consists of golden brown eggs; a fibrous tissue
•• Even when clinically suspected, patient must be isolated.
that may go for cavitation in some cases;
•• A staff who has known immunisation history should
•• Treatment: Praziquantel
nurse the patient.
122. Culture media for Legionella:
127. Coxsackie virus A causes:
a. BCYE agar b. Baird Parker medium
a. RMSF b. HFMD
c. Macconkey agar d. PLET medium
c. Yellow fever d. Pleurodynia
Ans.  (a) BCYE agar
Ans.  (b) HFMD
Ref: Harrisons T.B of medicine – 19th ed – page 1018
Ref: Greenwood – medical microbiology – 18th ed – page 487
•• Legionella isolation is done from respiratory secretions –
culture media is BCYE agar Coxsackie Virus Group Clinical Features
•• Buffered Charcoal Yeast Extract Agar (BCYE) A (1-24) •• Aseptic meningitis
•• Baird Parker agar – Staphylococci •• Febrile illness
•• MacConkey agar – Urine sample – to differentiate LF and •• Herpangina
NLF •• Hand, foot and mouth disease
•• PLET medium – Bacillus cereus (HFMD)
123. Special stain for Cryptococcus: B (1-6) •• Neonatal disease
a. Ziehl Neelsen stain b. Mucicarmine stain •• Bornholm disease
c. Malachite green d. Alberts stain •• Myocarditis
•• Hepatitis
Ans.  (b) Mucicarmine stain
•• Aseptic meningitis
Ref: Paniker T.B of microbiology – 10th ed – page 617
•• Stains for Cryptococcus: India Ink stain (negative stain) 128. Infection of following organism has clinical features
done for capsule demonstration and Mucicarmine stain resembling erythroblastosis foetalis?
in HPE a. Cytomegalovirus b. Ebstein Barr virus
•• Mucicarmine stain is also used for Rhinosporidium. c. Toxoplasmosis d. Herpes virus

124. Disk diffusion method is also known as: Ans.  (a) Cytomegalovirus
a. Kirby Bauer method b. E test method
c. MIC method d. Stokes method Ref: Greenwood – medical microbiology – 18th ed – page 439
•• Clinical features of congenital CMV infection is similar
Ans.  (a) Kirby Bauer method to those of Erythroblastosis fetalis
Ref: Paniker T.B of microbiology – 10th ed – page •• Symptoms are:
ƒƒ IUGR
•• Kirby Bauer method is the conventional method where ƒƒ Hepatosplenomegaly
antibiotic disks are kept in equal distance in a lawn ƒƒ Jaundice
culture of bacterium in Mueller Hinton agar. ƒƒ Thrombocytopenia
•• E test is Epsilometer test used for MIC detection ƒƒ Microcephaly
125. A child is suffering from recurrent chronic infections 129. All are true about congenital toxoplasmosis except:
with encapsulated bacteria; Which subclass of IgG does a. Chorioretinitis b. Jaundice
the child has deficiency? c. Macrocephaly d. Cerebral calcification
a. IgG1 b. IgG2
c. IgG3 d. IgG4 Ans.  (c) Macrocephaly
Ans.  (b) IgG2 Ref: Q.21
Ref: Review of medical microbiology and immunology – 13 th 130. An AIDS patient presented to OPD with dyspnoes and
ed – page 1127 respiratory illness; Which of the following is suitable to
•• IgG has four subclasses: IgG1, IgG2, IgG3 and IgG4 diagnose the opportunistic infection commonly seen in
•• IgG2 antibody is directed against polysaccharide AIDS patient?
antigens and hence it is most important defence against a. Sputum microscopy b. Broncho alveolar lavage
encapsulated bacteria. c. Chest Xray d. CT scan
38
 Section A  Recent Questions 2019

Ans.  (b) BAL •• Vector

ƒƒ Transmitted by culex tritaeniorrhynchus – most
Ref: Greenwood – medical microbiology – 18 ed – page 570
th
important vector, others are C.Vishnuii and c. Gelidus
•• Pneumocystis jirovecii pneumonia is more common in •• Incubation period is 5-15 days
AIDS patients. ƒƒ Case fatality rate – 20-40%
•• Fever, unproductive cough, progressive shortness of
133. Under RMNCH program peripheral level of planning is
breath are presenting complaints.
done at
•• Diagnosis is confirmed by:
a. Anganwadi b. Subcentre
ƒƒ Fungal cysts (Toluidine blue) from BAL
c. District level d. PHC level
ƒƒ Fungal DNA dectection by PCR
131. Identify the following life cycle: Ans.  (c) District level
(Ref: K Park, 24th ed p 472-474)
The RCH phase 1 was launched 1997 and phase 2 in
2005 which was extended till 2012. Thereafter 2013 with
expanded strategy in conjunction with NRHM, it was
renamed as Reproductive, Maternal, Neonatal, child &
Adolescent Health (RMNCH-A)
RCH 1 included maternal components, child
component, family planning and sexually transmitted
infections prevention and control in some selected
districts. Categorization of districts based crude birth rate
and female literacy rate for 3 consecutive years. It uses
differential approach to all districts.
134. Best chart to represent incidence of disease over a
period of time
a. Histogram b. Bar chart
c. Scatter plot d. Line diagram
a. Plague b. Japanese encephalitis
c. Influenza d. Nipah virus Ans.  (d) Line diagram
(Ref: K Park, 24th ed p 883)
Ans.  (b) Japanese encephalitis
Line diagram – trend of a event over a period of time
Ref: Greenwood – medical microbiology – 18th ed – page 530 and scatter plot relationship between two quantitative
•• From the image, it is understood that: variables.
ƒƒ Vector – mosquito (Culex) 135. Drug of choice for Diphtheria carriers is
ƒƒ Host and reservoir – Pigs (amplifiers) and Herons a. Penicillin b. Erythromycin
ƒƒ Accidental host – Humans c. Amoxycillin d. Tetracycline
The agent is Japanese encephalitis
Ans.  (b) Erythromycin

PSM (Ref: K Park, 24th ed p 171)

•• Clinical features
132. Which of the following disease with bird, arthropod and ƒƒ Present as pharyngo tonsillar form (most common),
human chain laryngo tracheal form (most severe) and nasal
a. Japanese encephalitis b. Plague diphtheria (mild form)
c. Malaria d. Paragomonous •• Control of diphtheria
ƒƒ Cases to be isolated for 14 days
Ans.  (a) Japanese encephalitis ƒƒ Treatment- cases- Antitoxin
ƒƒ Treatment Carriers – Erthromycin-10 day course(Q-2016)
(Ref: K Park, 24th ed p 302-303)
136. Test of significance used for 2 or more groups using
•• Agent factors
qualitative data (proportions)
ƒƒ Caused by group B arbovirus (flavivirus)
a. ANOVA b. Chi-square test
ƒƒ The main reservoirs are Ardeid birds and pigs
c. Fischer’s test d. Paired T test
ƒƒ Pigs are amplifiers of the virus and they do not
manifest overt symptoms but circulates the virus Ans.  (b) Qualitative data.
•• Host factors
ƒƒ Most common in the age group of <15 years of age (Ref: K Park, 24th ed p 889)
ƒƒ Man – incidental dead end host ANOVA is used for quantitative data with more than 2
ƒƒ Affects other animals also and horse is the only animal groups.
which does not shows symptoms of encephalitis
39
 Section A  Recent Questions 2019

137. Probability of a person with positive test result having 140. Which of the following comes under concurrent list
the disease is given by a. International immigration for quarantine
a. Sensitivity b. Prevention of communicable diseases
b. Specificity c. Mines and oilfield workers rules
c. Positive predictive value d. Establishment and maintenance of drug standards
d. Negative predictive value
Ans.  (b) Prevention of communicable diseases
Ans.  (c) Positive predictive value
(Ref: K Park, 24th ed p 915-916)
(Ref: K Park, 24 ed p 149-150)
th
Union list- Functions of the Union Government Only
Sensitivity is defined as the ability of a test to identify
•• International health regulations and port quarantine
correctly all those who have the disease (True positives)
(Q-2018)
•• Administration of central institutes (AIIMS)
•• Promote research and research bodies (ICMR)
Specificity is defined as the ability of a test to identify
•• Regulation of medical, dental and nursing profession
correctly those who do not have the disease (True
•• Establishment and maintenance of drug standards
Negatives)
•• Census and other data publications
Diagnostic power of the test(Q-2017)
•• Immigration and emigration
Positive predictive value - Indicates the probability a
•• Regulation of labor in working of mine and oil fields
person with a positive test result having the disease. It
•• Coordination with states in promotion of health
depends on sensitivity, specificity of the test and prevalence
of the disease. It is directly proportional with the prevalence Concurrent List- Responsibilities of Both State End
of the disease. Central Government
Negative predictive value- Probability a person with a •• Prevention of communicable disease
negative test result not having the disease. •• Prevention of adulteration of food
138. To call it as fast breathing in a child of 6 months of age, •• Control of drugs and poisons
the respiratory rate should be more than •• Vital statistics
a. 40 b. 50 •• Labor welfare
c. 60 d. 30 •• Port other than major
•• Economic and social planning
Ans.  (b) 50 •• Population control and family planning
(Ref: K Park, 24th ed p 180) 141. Vaccine contraindicated in pregnancy
a. Rabies b. Hep A
•• Fast breathing c. Hep B d. Varicella
ƒƒ 60 per min or more in a child less than 2 months of age
ƒƒ 50 per min or more in a child aged 2 months to 12 Ans. (d) Varicella. In pregnancy all live vaccines are
months contraindicated except yellow fever.
ƒƒ 40 per min or more in a child aged 12 months up to
5 years (Ref: K Park, 24th ed p 108)

139. Which of the following not a epidemiological indicator 142. A 2 year old boy with Vitamin A deficiency is treated with
for malaria a. 1 lakh IU on days 0,1,6 b. 2 Lakh IU on days 0,1,6
a. Annual blood examination rate c. 2 lakh IU on days 0,1,14 d. 1 lakh IU on days 0,1,14
b. Annual parasite incidence
c. Annual parasite index Ans.  (c) 2 Lak IU on days 0,1,14
d. Annual falciparum incidence (Ref: K Park, 24th ed p 654)
Ans.  (c) Annual Parasite index, •• Treatment for Vitamin A deficiency is given 3 doses.
Days 0,1,14 with doses appropriate for the age. Less than
(Ref: K Park, 24th ed p 278) six months of age-50000 IU per dose, 6-12 months of
Malariometric Measures in Eradication Era age-100000 IU and >1 year- 200000 IU per dose.
•• Annual parasitic incidence (API): Sophisticated 143. How much land is required for a population of 10000, to
measure of malaria incidence in a community have a deep trench
Confirmed cases during one year a. 1 acre b. 2 acre
API = × 1000 c. 3 acre d. 5 acre
Population under surveillance
•• Annual blood examination rate (ABER): (Index of Ans.  (a) 1 acre
operational efficiency)
(Ref: K Park, 24th ed p 791)
Number of slides examined •• Sanitary landfill(controlled tipping)- most satisfactory
ABER = × 100
Population method when land is available

40
 Section A  Recent Questions 2019

ƒƒ Trench, ramp, area method. In trench method it Ans.  (a) Case control study
is estimated that one acre of land per year will be
(Ref: K Park, 24th ed p 78)
required for 10000 population.
It is the other name for Odd’s ratio given by the formula ad/
144. Identify the graph
bc
148. Test of significance used for 2 independent means is
a. Paired t test b. Unpaired t test
c. ANOVA d. Chi-square test

Ans.  (b) Unpaired t test

(Ref: Textbook on Biostatistics- Mahajan)
For a quantitative data with 1 group before and after –
paired t test
149. Following disaster green colour of triage used for which
patients
a. Dead b. Medium priority
c. High priority d. Ambulatory
a. Histogram b. Simple bar chart Ans.  (d) Ambulatory
c. Multiple bar chart d. Component bar chart
(Ref: K Park, 24th ed p 833)
Ans.  (d) Component bar chart
TRIAGE(Q-2017)
(Ref: K Park, 24th ed p 882)
•• The principle of first come first served is not followed in
145. Based on WHO criteria, severe acute malnutrition is mass emergencies
defined as •• Triage consists or rapidly classifying the injured on the
a. Weight for age < 2 standard deviation basis of severity of their injuries and the likelihood of
b. Weight for age < 3 standard deviation their survival with prompt medical intervention
c. Weight for age < 1 standard deviation •• Four color code system
d. Weight for height < 1 standard deviation ƒƒ Red –high priority
ƒƒ Yellow – medium priority
Ans.  (b) Weight for age < 3 standard deviations
ƒƒ Green – ambulatory patients
(Ref: K Park, 24th ed p 582) ƒƒ Black – dead or moribund patients
•• Growth chart used in India shows normal zone of 150. Dose of diphtheria antitoxin is
weight for age, undernutrition (below 2 SD) and severely a. 1000-5000 IU b. 20000-1000000 IU
malnutrition zone (below 3 SD) c. 1000-2000 IU d. None
•• ICDS growth chart based on WHO growth charts
Ans.  (b) 20000-100000 IU,
Uses of Growth Chart:
•• Growth monitoring tool (Ref: K Park, 24th ed p 171)
•• Diagnostic tool for identifying high risk children 151. Which among the following not a personal protective
•• Planning and policy making equipment?
•• Educational tool a. Goggles b. Face shield
•• Tool for action c. Gloves d. Lab coat
•• Evaluation of corrective measures and impact of a
programme Ans.  (b) Face shield
•• Tool for teaching
(Ref: K Park, 24th ed p 851)
146. Which of the vaccine strain changed every year
a. Measles b. Mumps 152. Confounding factor is defined as
c. Polio d. Influenza a. Factor associated with both the exposure and the
disease and is distributed unequally in study and
Ans.  (d) Influenza control groups.
b. Factor associated with exposure only and is distributed
(Ref: K Park, 24th ed p 164)
unequally in study and control groups.
Influenza virus under goes antigenic shift and causes c. Factor associated with both the exposure and the
epidemics and pandemics. It requires vaccine strain also to disease and is distributed equally in study and control
be changed regularly groups
147. Cross product ratio is calculated in which study d. Factor associated with the disease and is distributed
a. Case control study b. Cohort study equally in study and control groups
c. Cross sectional study d. Ecological study
41
 Section A  Recent Questions 2019

Ans.  (a) Factor associated with both the exposure and

disease and is distributed unequally in study and control
groups
(Ref: K Park, 24th ed p 78)
153. In a normal curve what is the area that comes under 1
standard deviation
a. 50% b. 68%
c. 95% d. 100%

Ans.  (b) 68%

(Ref: K Park, 24th ed p 886) 155. Osborn J waves is seen in
a. Hypothermia b. Hyperkalemia
Normal Curve (De Moirre and Gauss) c. Hypocalemia d. Hypokalemia
•• Bell shaped, bilaterally symmetrical infinitely large
number of observations Ans.  (a) Hypothermia
•• Area of the curve is 1
Ref: 1. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
•• Mean median and mode all coincide which is 0
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
•• Standard deviation and variance- 1
20th edition Page:3338
•• Mean + I SD= 68 % area
•• Mean + 2 SD= 95 % area 2. Krantz MJ, Lowery CM. Giant Osborn waves in
•• Mean + 3 SD= 99% area hypothermia. New England Journal of Medicine. 2005 Jan
13;352(2):184-.
Accidental hypothermia occurs when there is an
MEDICINE unintentional drop in the body’s core temperature below
35°C (95°F).
154. A 26 year old female patient presented with oral ulcers, At this temperature, many of the compensatory physiologic
sensitivity to light and rash over the malar area of the mechanisms that conserve heat begin to fail.
face sparing the nasolabial folds of both side.which of
the following indicates the condition associated:
a. Sturge weber syndrome
b. SLE
c. Dermatitis
d. Psoriasis Primary accidental hypothermia is a result of the direct
exposure of a previously healthy individual to the cold.
Ans.  (b) SLE
Secondary hypothermia as a complication of a serious
Ref: 1. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, systemic disorder or injury.
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine, Risk factors for Hypothermia
20th edition Page 2519;
Age extremes Endocrine-related
2. Feily A. Acute onset of a severe rash on the face and •• Elderly •• Diabetes mellitus
dorsal hands. Dermatology practical & conceptual. 2017 •• Neonates •• Hypoglycemia
Apr;7(2):67. Environmental exposure •• Hypothyroidism
•• Systemic lupus erythematosus (SLE) is a chronic disease •• Occupational •• Adrenal insufficiency
that can affect any organ system. •• Sports-related •• Hypopituitarism
•• Its clinical manifestations are highly variable, ranging •• Inadequate clothing Neurologic
from chronic to fulminant. •• Immersion •• Cerebrovascular accident
•• Cutaneous lupus erythematosus (CLE) is the second Toxicologic and •• Hypothalamic disorders
most common finding of SLE. pharmacologic •• Parkinson’s disease
•• In a majority of cases, CLE is the main and sometimes •• Ethanol •• Spinal cord injury
the only feature of the disease independent of systemic •• Phenothiazines Multisystemic
involvement. •• Barbiturates •• Trauma
The most common acute SLE rash is malar rash is a •• Anesthetics •• Sepsis
photosensitive, slightly raised erythema, occasionally •• Neuromuscular •• Shock
scaly, on the face (particularly the cheeks and nose—the blockers •• Hepatic or renal failure
“butterfly” rash), ears, chin, V region of the neck and chest, •• Antidepressants •• Carcinomatosis
upper back, and extensor surfaces of the arms. Insufficient fuel •• Burns and exfoliative
Worsening of this rash often accompanies flare of systemic •• Malnutrition dermatologic disorders
disease. •• Marasmus •• Immobility or debilitation
•• Kwashiorkor
42
 Section A  Recent Questions 2019

Physiologic Changes Associated With Accidental Hypothermia

Severity Body Central Nervous Cardiovascular Respiratory Renal and Neuromuscular

Temperature System Endocrine
Mild 35°C (95°F)– Linear depression Tachycardia, Tachypnea, then Diuresis; increase Increased
32.2°C (90°F) of cerebral then progressive progressive in catecholamines, preshivering
metabolism; bradycardia; cardiac decrease in adrenal steroids, muscle tone, then
amnesia; apathy; cycle prolongation; respiratory triodothyronine and fatiguing
dysarthria; vasoconstriction; minute volume; thyroxine; increase;
impaired judgment; increase in cardiac declining oxygen in metabolism with
maladaptive output and blood consumption; shivering
behavior pressure bronchorrhea
bronchospasm
Moderate < 32.2°C EEG abnormalities; Progressive decrease Hypoventilation; 50% increase Hyporeflexia;
(90°F)–28°C progressive in pulse and cardiac 50% decrease in in renal blood diminishing
(82.4°F) depression of level output; increased carbon dioxide flow; renal shivering-induced
of consciousness; atrial and ventricular production per autoregulation thermogenesis;
pupillary dilation; arrhythmias; 8°C (17.6°F) drop intact; impaired rigidity
paradoxical suggestive (J-wave) in temperature; insulin action
underssiing; ECG changes absence of
hallucination protective
airway reflexes
Severe <28°C (<82.4°F) Loss of Progressive Pulmonic Decrease in renal No motion;
cerebrovascular decrease in blood congestion blood flow that decreased
autoregulation; pressure, heart and edema; parallels decrease nerveconduction
decline in cerebral rate, and cardiac 75% decrease in cardiac output; velocity;
blood flow; output; reentrant in oxygen extreme oliguria; peripheral
coma; loss of dysrhythmias; consumption; poikilothermia; 80% areflexia; no
ocular reflexes; maximal risk apnea decrease in basal corneal or
progressive of ventricular metabolism oculocephalic
decrease in EEG fibrillation; asystole reflexes
abnormalities

•• In 1953, Dr. John Osborn described the J wave as an

“injury current” resulting in ventricular fibrillation
during experimental hypothermia.
•• Initial stage of hypothermia - sinus tachycardia develops
•• Temperature below 90 degree F - sinus bradycardia with
progressive prolongation of PR interval, QRS complex
and QT interval
•• 86 degree F - atrial ectopic activity ( can progress to atrial
fibrillation). 80% of patients show osborn waves which
consist of an extra deflection at the end of QRS complex.
•• More recent findings suggest that hypothermia increases
the epicardial potassium current relative to the current
in the endocardium during ventricular repolarization.
This transmural voltage gradient is reflected on the
surface electrocardiogram as a prominent J, or Osborn,
wave. 156. Which of the following is included in Essential major
•• The differential diagnosis of prominent Osborn waves blood culture criteria for infective endocarditis?
includes early repolarization, hypercalcemia, and the a. Single positive culture of HACEK
Brugada syndrome. b. Single positive culture of coxiella
c. Single positive culture of cornybacterium
d. Both a & b

Ans.  (b) Single positive culture of coxiella

Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition page 921
43
 Section A  Recent Questions 2019

•• Prototypic lesion of infective endocarditis - vegetation The Modified Duke Criteria for the Clinical Diagnosis
(mass of platelets, fibrin, microorganisms and scant of Infective Endocarditis
inflammatory cells
•• Most common sites involved - heart valves, but may Major Criteria
also occur on the low pressure side of a ventricular 1. Blood cultures positive for IE
septal defect, on mural endocardium damaged by •• Typical microorganism consistent with IE from 2 separate
foreign bodies or sudden aberrant jets of blood, or on blood cultures:
intracardiac devices „„ Viridans streptococci, Streptococcus gallolyticus
•• Infective endarteritis - the analogous process that (Streptococcus bovis). HACEK group, Staphylococcus
involves arteriovenous shunts , arterio arterial shunts aureus: or
(PDA), or a coarctation of aorta „„ Community-acquired enterococci, in the absence of a
•• Although many species of bacteria and fungi cause primary focus; or
sporadic episodes of endocarditis, a few bacterial species •• Microorganisms consistent with IE from persistently positive
cause the majority of cases. blood cultures:
•• The oral cavity, skin, and upper respiratory tract are „„ ≥2 positive blood cultures of blood samples drawn > 12 h
the respective primary portals for apart of
ƒƒ Viridans streptococci, „„ All of 3 or a majority of ≥4 separate cultures of blood (with
ƒƒ Staphylococci, first and last samples drawn ≥1 h apart): or
Clinical and Laboratory Features of Infective Endocarditis •• Single positive blood culture for Coxiella burnetii or phase I
IgG antibody titre > 1:800
Feature Frequency (%)
2. Imaging positive for IE
Fever 80-90 •• Echocardiogram positive for IE
„„ Vegetation
Chills and sweats 40-75
„„ Abscess, pseudoaneurysm, intracardiac fistula:
Anorexia, weight loss, malaise 25-50 „„ Valvular perforation or aneurysm
„„ New partial dehiscence of prosthetic valve
Myalgias, arthralgias 15-30
•• Abnormal activity around the site of prosthetic valve
Back pain 7-15 implantation detected by 10F.FDG PET/CT (Only if the
prosthesis was implanted for >3 months) or radiolabelled
Heart murmur 80-85
leukocytes SPECT/CT
New/worsened regurgitant 20-50 •• Definite paravalvular lesions by cardiac CT
murmur
Minor Criteria
Arterial emboli 20-50
•• Predisposition such as predisposing heart condition, or
Splenomegaly 15-20 injection drug use
•• Fever defined as temperature > 38°C
Clubbing 10-20 •• Vascular phenomena (including those detected by imaging
Neurologic manifestations 20-40 only): major arterial emboli; septic pulmonary infarcts,
infectious (mycotic) aneurysm, intracranial haemorrhage,
Peripheral manifestations 2-15 conjunctival haemorrhages, and Janeway’s lesions.
(Osler’s nodes subungual •• Immunological phenomena: glomerulonephritis, Osler’s
hemorrhages, Janeway lesions, nodes, Roth’s spots and rheumatoid factor
Roth’s spots) •• Microbiological evidence: Positive blood culture but does
not meet a major criterion as noted above or serological
Petechiae 10-40 evidence of active infection with organism consistent with IE
Laboratory manifestations 1
157. A man who is chronic alcoholic will develop which type
Anemia 70-90 of cardiomyopathy?
a. Hypertrophic cardiomyopathy
Leukocytosis 20-30 b. Dilated cardiomyopathy
Microscopic hematuria 30-50 c. Pericarditis
d. Myocarditis
Elevated erythrocyte 60-90
sedimentation rate Ans.  (b) Dilated Cardiomyopathy
Elevated C-reactive protein >90 Ref: 1. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
level Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition Page 1779
Rheumatoid factor 50
2. Binham J, Fredlund V. A case of dilated cardiomyopathy.
Circulating immune complexes 65-110
Rural and remote health. 2012 Nov 2;12(2143).
Decreased serum complement 5-40 Cardiomyopathy is disease of the heart muscle.
44
 Section A  Recent Questions 2019

Types of Cardiomyopathy

Type Description
Dilated Severe dilation of heart chambers without heart-valve abnormalities; non-specific thickening of inner layer of
heart chambers; heart muscles stretch and weaken, resulting in insufficient perfusion to organs
Hypertrophic Enlarged heart with asymmetric hypertrophy between left and right ventricles; cardiac fibers extremely
enlarged and disrupted by fibrous tissue; prevents adequate blood flow from ventricles
Restrictive Development of scar tissue, which is caused by the extreme thickening of inner layer of ventricles; superim-
posed thrombi may congest ventricles; characterized by incomplete ventricular filling
Arrhythmogenic right Right ventricles primarily involved; decreased movement in wall of right ventricles; muscle tissue in right
ventricular dysplasia ventricles replaced with fibrous tissue; right ventricular tissue death and development of scar tissue are
direct result of disrupted electrical firing.
Presentation with Symptomatic Cardiomyopathy
Dilated Restrictive Hypertrophic
Election fraction (normal > 55%) Usually <30% when symptoms 25-50% >60%
severe
Left ventricular diastolic dimen- >60 <60 mm (may be decreased) Often decreased
sion (normal <55 mm)
Left ventricular wall thickness Decreased Normal or increased Markedly increased
Atrial size Increased Increased; may be massive Increased; related to abnormal
Valvular regurgitation Related to annular dilation; Related to endocardial Related to valve-septum
mitral appears earlier, during involvement; frequent mitral interaction; mitral regurgitation
decompensation; tricuspid and tricuspid regurgitation,
regurgitation in late stages rarely sever
Common first symptoms Exertional intolerance Exertional intolerance, fluid Exertional intolerance; may have
retintion early chest pain
Congestive symptomsa Left before right, except right Right often dominates Left-sided congestion may
prominent in young adutls develop lae
Arrhythmia Ventricular trachaarhythmia; Ventricular uncommon except Ventricular trachyaarhythmias;
conduction block in Chagas’ in sarcoidosis conduction block atrial fibrillation
disease, and some families; in sarcoidosis and amyloidosis;
atrial fibrillation. atrial fibrillation.
Left-sided symptoms of pulmonary congestion; dyspnea on exertion, orthopnea, paroxymal nocturnal dyspnea. Right-sided symptoms of
Systemic versus congestion: discomfort on bending, hepatic and abdominal distention, peripheral edema.

Causes for Dilated Cardiomyopathy

Category Cause
Vascular Ischaemic
Infective Viral (eg enterovirus, coxsackie, HIV)
BACTERIAL (EG Group A beta haemolytic strep, Lyme disease)
Parasitic (eg Chagas)
Inflammatory Sarcoidosis
Autoimmune Systemic lupus erythematosus
Metabolic Heamachromatosis
Endocrine Hyperthyroid
Drug related Alcohol
Cocaine
Chemotheraputic agents (eg Doxorubicin)
Heavy metals (eg cobalt)
Congenital/genetic Autosomal dominant mutations in cytoskeleton proteins (eg alph-cardiac actin)
Autosomal recessive (eg Alstrom syndrome)
X-linked (eg Duchenne muschalar dystrophy)
Mitochondrial 45
Idiopathic Peri-/post-partum
 Section A  Recent Questions 2019

•• Alcohol is the most common toxin implicated in chronic

DCM.
•• Excess consumption may contribute to more than 10%
of cases of heart failure, including exacerbation of cases
with other primary etiologies such as valvular disease or
previous infarction.
•• Toxicity is attributed both to alcohol and to its primary
metabolite, acetaldehyde.
•• Polymorphisms of the genes encoding alcohol
dehydrogenase and the angiotensin converting enzyme
may influence the likelihood of alcoholic cardiomyopathy
in an individual with excess consumption.
•• Superimposed vitamin deficiencies and toxic alcohol
additives are rarely implicated currently.
•• Atrial fibrillation occurs commonly both early in the
disease (“holiday heart syndrome”) and in advanced
stages. Harsh mid systollc crescendo-decrescendo murmur S4
•• Medical therapy includes neurohormonal antagonists
and diuretics as needed for fluid management. ↑Murmur ↓Murmur
158. Which of the following murmur increases on standing? •• Valsalva •• Squatting
a. HOCM b. MR •• Standing up •• Trendelenberg
c. MS d. VSD
Characteristic ECG findings
Ans.  (a) HOCM •• Large-amplitude QRS complexes
•• Deep narrow Q-waves in the inferior or lateral leads or both,
Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, mimicking inferior or lateral myocardial infarction
Loscalzo J. ... Harrison’sTM Principles of Internal Medicine, •• Tall R-waves in leads V1-V2 which mimic posterior myocardial
20th edition Page 243 infarction or right ventricular hypertrophy
•• HOCM is associated with a midsystolic murmur(loudest Clinical Management
along the left sternal border / between the left lower •• Young patient •• Beta-blockers and calcium
sternal border and the apex •• Exertion syncope channel blockers decrease
•• The murmur is produced in both MR and dynamic •• Dyspnea on exertion obstruction
left ventricular outflow obstruction. Therefore its
configuration is a hybrid between regurgitant and Avoid positive inotropes and nitrates (worsens obstruction)
ejection phenomena. The murmur intensity varies
from beat to beat and after provocation maneuvers
and does not exceed grade 3. The murmur increases in
intensity following maneuvers that increase the degrees
of outflow tract obstruction like reduction in preload or
afterload (vasodilators, standing, valsalva). The intensity
of murmur is decreased by maneuvers that increase
preload (volume administration, passive leg raising,
squatting) or afterload (vasopressors, squatting) or that
reduce contractility (beta blockers)

An important table to revise before exam dear friends:

Maneuver Effect HOCM AS MVP MR

Valsalva Decr Blood Return Incr Decr Incr Decr
Standing to LV
Hypertrophic Cardiomyopathy Laying Incr Blood Return Decr Incr Decr Incr
Down to LV
Squatting
Straight Leg
Raise
Contd…

46
 Section A  Recent Questions 2019

Hand Increased Afterload Decr Decr Decr Incr

Isogrip Phe-
nylephrine
Amyl Ni- Decreased Afterload Incr Incr Incr Decr
trate
Post PVC Decr Afterload > Incr Incr Decr Decr
Incr Vol (Incr Dias-
tolic Time)

159. Which of the following statements is true about the

bundle of kent?
a. Abnormal pathway between two atria
b. It is muscular or nodal pathway between the atria and
ventricle in WPW syndrome
c. It is slower than the AV nodal pathway
d. None

Ans.  (b) It is muscular or nodal pathway between the

atria and ventricle in WPW syndrome
Ref : Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition Page 1731
•• In the normal heart, atrioventricular conduction
occurs across the specialized axis comprising the
atrioventricular node (with its zones of transitional 160. Type of sensation lost on same side of Brown Sequard
cells), the bundle of His, and the ventricular conduction syndrome is:
pathways. This axis, for conduction to be normal, must a. Pain b. Touch
be the solitary muscular connection between the atria c. Proprioception d. Temperature
and the ventricles.
•• Accessory pathways (APs) occur in 1 in 1500– Ans.  (c) Proprioception
2000 people and are associated with a variety of
Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
arrhythmias including narrow-complex PSVT, wide-
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
complex tachycardias, and, rarely, sudden death.
20th edition Page: 3173
•• Most patients have structurally normal hearts, but APs
are associated with Ebstein’s anomaly of the tricuspid •• Definition - hemisection of spinal cord, often in the
valve and forms of hypertrophic cardiomyopathy cervical cord
including PRKAG2 mutations, Danon’s disease, and •• Causes- unilateral compression through trauma
Fabry’s disease. ƒƒ Less common cause-disc herniation, spinal
•• WPW syndrome - accessory connections between epidural hematoma, spinal epidural abscess
artium and ventricle. This bypass tract may or tumor, multiple sclerosis, complication of
be atriofascicular, fascicular, intranodal, or decompression sickness
nodoventricular (m/c is the atrioventricular pathway •• Clinical features on Same side
or Bundle of Kent). Conduction through this bundle ƒƒ Below the level of lesion - loss of proprioception,
can be either anterograde, retrograde, or both. tactile discrimination, vibration , spastic paralysis
Accessory pathways capable of only retrograde and Babinski sign
conduction - called as “concealed” ƒƒ At the level of lesion - segmental flaccid paresis
•• Accessory pathways capable of anterograde •• Clinical features on opposite side
conduction - called as “manifest” ƒƒ loss of pain and temperature one or two levels
•• If the impulse from the sinus node conducts through below lesion
the AP to the ventricle (antegrade) before the impulse •• Clinical Diagnosis
conducts through the AV node and His bundle, then the ƒƒ Consider CT in case of trauma
ventricles are preexcited during sinus rhythm, and the ƒƒ Consider MRI in case of tumor suspect
ECG shows •• Treatment
ƒƒ A short P-R interval (<0.12 s), ƒƒ Management of spinal cord injuries (eg-steroids
ƒƒ Slurred initial portion of the QRS (delta wave), and to reduce swelling, or surgery depending on the
ƒƒ Prolonged QRS duration produced by slow underlying condition)
conduction through direct activation of ventricular ƒƒ Prognosis - poor
myocardium over the AP.

47
 Section A  Recent Questions 2019

161. MELD score includes

a. Serum creatinine
c. Albumin
b. Transaminase
d. Alkaline phosphatase
 Note
•• If the patient has been dialyzed twice within the last 7 days,
Ans.  (a) Serum creatinine then the value for serum creatinine used should be 4.0
Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, •• Any value less than one is giv en a value of 1 (i.e. if bilirubin
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine, is 0.8, a value of 1.0 is used) to prevent the occurrence of
20th edition page 2416 scores below 0 (the natural logarithm of 1 is 0, and any value
below 1 would yield a negative result)
Model For End-Stage Liver Disease (MELD) for Ages 12
and Older •• Score: 6 in healthy person to 40 in severe ESLD
•• Score <15 should not undergo liver transplantation
•• The Model for End Stage Liver Disease (MELD) predicts
survival for patients with advanced liver disease. 3- Month Mortality based on MELD scores
•• The United Network for Organ Sharing (UNOS) made a The estimated 3-month mortality based on MELD score
policy change regarding a revision in the MELD scoring highlighted in yellow above.
system on January 11, 2016 that is related to transplant
listing. MELD Score Mortality Probability
•• The new MELD scores are calculated first by 40 71.3% mortality
determining the traditional MELD score as an initial 30-39 52.6% mortality
score (MELD(i));
•• If the initial MELD(i) scores is 12 or greater, the score is 20-29 19.6% mortality
adjusted by incorporating the serum sodium value. 10-19 6.0% mortality

Model for End Stage Liver Disease (MELD) Score 9 or less 1.9% mortality

MELD = 3.78 × loge serum bilirubin (mg/dL) + Example: Revised MELD Score (with Sodium)
11.20 × loge INR +
Creatinine = 1.9 mg/dL, billirubin = 4.2 mg/dL, INR = 1.2,
9.57 × loge serum creatinine (mg/dL) + sodium = 133 mEq/dL
6.43 (constant for liver disease etiology)
•• Calculate original MELD(i) = (0.957 × Loge 1.9) + (0.378 ×
Loge 4.2) + (1.120 × Loge 1.2) + 0.643 = 2.0039, multiply by
10 and round: 20
•• Formula: (Revised) MELD = MELD + 1.32 × (137–Na) –
[0.033 × MELD* (137-Na)]

48
 Section A  Recent Questions 2019

Recalculate: MELD = 20 + 1.32*(137–133) – [0.33*20*(137– ƒƒ congenital mitral valve stenosis,

133)] = 23 ƒƒ cor triatriatum,
For Na = 127, the new score would be 27 ƒƒ mitral annular calcification with extension onto the
For Na = 135, the new score would be 21 leaflets,
162. Infarcts involving which part of the myocardium cause ƒƒ systemic lupus erythematosus,
aneurysm as a post-Myocardial infarction complication? ƒƒ rheumatoid arthritis,
a. Subendocardial MI ƒƒ left atrial myxoma, and
b. Anterior transmural MI ƒƒ infective endocarditis with large vegetations.
c. Posterior transmural MI •• Pure or predominant MS occurs in ~40% of all patients
d. Inferior wall MI with rheumatic heart disease and a history of rheumatic
fever.
Ans.  (b) Anterior transmural MI Mitral Stenosis Pathophysiology
Ref: Friedman BM, Dunn MI. Postinfarction ventricular
aneurysms. Clinical cardiology. 1995 Sep;18(9):505-11.
•• Ventricular aneurysms are circumscribed, thinwalled
fibrous, noncontractile outpouchings of the ventricle.
•• An aneurysm is a severely scarred portion of infarcted
ventricular myocardium that does not contract normally.
•• A  ventricular aneurysm  may develop in some patients
following a large MI (especially anterior).
•• Instead, during ventricular systole the aneurysmal
portion bulges outward while the rest of the ventricle is
contracting. 
•• Ventricular aneurysms may occur on the anterior or
inferior surface of the heart.
Chest Xray:
The earliest changes are
•• Straightening of the upper left border of the cardiac
silhouette,
•• Prominence of the main PAs,
•• Dilation of the upper lobe pulmonary veins, and
•• Posterior displacement of the esophagus by an enlarged
LA.
•• Kerley B lines are fine, dense, opaque, horizontal lines
that are most prominent in the lower and mid-lung
fields that result from distention of interlobular septae
and lymphatics with edema when the resting mean LA
pressure exceeds ~20 mmHg.

Fig.  Ventricular Aneurysm

163. Which wall of heart is enlarged first in a patient with
mitral stenosis ?
a. Left atrium b. Right atrium
c. Left ventricle d. Right ventricle

Ans.  (a) Left atrium

Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition page 1813
•• Rheumatic fever is the leading cause of mitral stenosis
(MS).
•• Other less common etiologies of obstruction to left
ventricular inflow include:

49
 Section A  Recent Questions 2019

Mutations in Alzheimers
Chromo Known Gene defect Phenotype
some Mutation
14 150 familial Presenilin 1 ↑Production
AD-causing mutation of Aβ42
mutations peptides
1 10 Presenlin 2 ↑Production
mutation of Aβ42
peptides
6 TREM2 ↑Density
of Aβ42
peptides
19 ApoE4 ↑Density of
polymorphi Aβ plaques
sm (∈4 allele) & vascular
deposits
21 25 β-APP
mutations

164. Risk factors for alzheimer’s disease include?

a. Klinefelter syndrome b. Noonan syndrome
c. Down’s syndrome d. None

Ans.  (c) Down’s syndrome

Ref: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition page 3109
•• Approximately 10% of all persons aged >70 years have
significant memory loss, and in more than half the cause
is Alzheimer’s disease (AD).

•• Several genes play an important role in the pathogenesis

of AD. One is the APP gene on chromosome 21.
•• Adults with trisomy 21 (Down’s syndrome) consistently
develop the typical neuropathologic hallmarks of AD if
they survive beyond age 40 years, and many develop a
progressive dementia superimposed on their baseline
mental retardation.
•• The extra dose of the APP gene on chromosome 21 is the
initiating cause of AD in adult Down’s syndrome and
results in excess cerebral amyloid production

50
 Section A  Recent Questions 2019

165. Identify the condition associated with the following

ECG?

a. Atrial fibrillation b. Arrhythmia

c. Atrial flutter d. Cardiomyopathy SURGERY

Ans.  (c) Atrial Flutter

Section 1: General Surgery, Trauma and transplant:
Ref:
166. Identify the Knot shown here: 
1. Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
 (Recent Pattern 2019 Question)
Loscalzo J. ...Harrison’sTM Principles of Internal Medicine,
20th edition page 1743
2. Daoud EG, Morady F. Pathophysiology of atrial flutter.
Annual review of medicine. 1998 Feb;49(1):77-83.
•• Atrial flutter presents as a macroreentrant
tachyarrhythmia that is very often contained within
the right atrium. Typical atrial flutter on ECG appears
as classic “ sawtooth “ pattern of flutter waves with a
negative polarity in leads II, III and aVF.
•• Atrial fibrillation is sustained by multiple reentrant
wavelets defined by the anatomic and/or functional a. Reef knot b. Granny Knot
barriers. c. Surgeon knot d. Aberdeen knot
•• Typical atrial flutter is sustained by a single reentrant
circuit that is defined by anatomical barriers. The Ans.  (b) Granny knot
isthmus of atrial tissue which is bordered by the inferior (Ref. Surgery Sixer 3rd Edition Page 42)
vena cava and the tricuspid annulus forms a critical zone
There are two important knots you must know and avoid
of slow conduction in the reentry atrial flutter circuit.
confusion for exams:
Granny knot ( Slip Knot) Square Knot (Reef Knot)
Two throws of same type made Two throws of opposite type
made
Right side suture over the left Right side suture run over the
and then the again same way left and then left side suture
right over left is made run over the right.

This is slipping knot, helps to This is a secure knot and gets

place the knot at exact site from tightened well.
a long distance. But it is not tight
and hence we have to secure it
with a Square knot at the end.
Contd…
51
 Section A  Recent Questions 2019

Bailey and Love page 52, added in Surgery Sixer 3rd

Tips to remember Image: Tips to remember Image:
Edition Page 39)
Granny slips- Above, Below, Square reefs tight – Above,
Above and below Below, Below and Above ( National Health Service UK Guidelines:
( See the Blue Suture running See Blue suture running over •• Use face full mask ideally with Protective spectacles.
over Red) red) •• Use of waterproof, disposable gowns and drapes.
•• Avoid Clogs and wear Boots to prevent sharp injuring
167. What is the Size of this blade used in incision and leg.
Drainage?  (Recent Pattern 2019 Question) •• Double Glove is needed ( with large size on inside is
more comfortable)
•• Allow only essential personal in theatre
•• Avoid unnecessary movement in theatre.
•• Meticulous technique needed.
169. An intern while doing Scalp suture injured his index
finger. Which is not done? 
 (Recent Pattern 2019 Question)
a. Should inform authorities
a. 15 size b. 22 size b. HIV transmission high in surgical needle injury
c. 11 size d. 13 size c. Injury during Suturing more common in Non Dominant
Index Finger
Ans.  (c) 11 Size
d. Show the finger in Running Water
(Ref. Surgery Sixer 3rd Edition Page 39)
•• There are 3 blades commonly used by Surgeons: Ans.  (b) HIV transmission high in Surgical needle injury
ƒƒ 11’ size- For Incision and Drainage of Abscess, (Ref. Surgery Sixer 3rd Edition Page 39)
Arteriotomy
ƒƒ 15’ Size- For precise cosmetic incisions After Contamination Prevention in HIV:
ƒƒ 22’ Size- For Long Incisions and Laparotomy Incisions (Direct paragraph from Bailey and Love 27th Edition page
52, Not completely updated in Surgery Sixer but a few
points mentioned regarding this issue in Page 39)
•• Needle stick injury is commonest on Non Dominant
Index Finger** during Surgery.
•• Hollow needles** used for injection carries high risk
than surgical needles .
•• Injured part is washed under running water.
•• Incidence is reported to authorities.
•• Local policies decide on ART treatment.
•• Post exposure testing is done.

Some added points from Schwartz 10th edition Page 156:

•• Surgeons have low risk than nurses and non surgical
physicians.
•• Incidence= 0.3% on injury from HIV positive patient.
•• Post exposure prophylaxis is given if injured with ART 2/3
drug regimen.
•• If patient’s status is not known , better carry out ART
prophylaxis especially in a high risk person like Narcotic use
while the testing is going on.
•• Unknown source contamination from tissues etc doesn’t
need prophylactic therapy.

168. Not a part of personal protective kit:  170. Water soluble contrast made up of 
 (Recent Pattern 2019 Question)  (Recent Pattern 2019)
a. Face mask b. Gloves a. Barium b. Calcium
c. Goggle d. Lab coat c. Iodine d. Bromine

Ans.  (d) Lab coat Ans.  (c) Iodine

(Ref. Surgery Sixer 3rd Edition Page 39) (Ref. Surgery Sixer 3rd Edition Pager 327)
•• Universal Precautions kit (Updated point in 27th Edition There are two types of Water soluble contrast:

52
 Section A  Recent Questions 2019

High Osmolar Low Osmolar Section 2: Head and Neck, Thyroid, Endocrine and
Gastrograffin contrast made up of Iohexol
Breast
Sodium Diatrazoate and Meglumine (Omnipaque)
174. Parathyroid Gland accidentally removed and found after
Diatrazoate is commonly used contrast made up
surgery is implanted in (Recent Pattern 2019 Question)
of  Iodine
a. Sartorius b. Biceps
On aspiration there is risk of Highly safe c. Brachioradialis d. Triceps
Pulmonary edema contrast.
Ans.  (c) Brachioradialis
171. If a mother is donating here kidney to her son- This is an (Ref. Surgery Sixer 3rd Edition Page 235)
example of  (Recent Pattern 2019)
a. Isograft b. Allograft •• Accidentally removed Parathyroid Gland found after
c. Autograft d. Xenograft surgery in Specimen is kept in non Dominant hand
Brachioradialis muscle*
Ans.  (b) Allograft •• If the parathyroid is identified during Surgery it must be
inserted in the Sternocleidomastoid muscle pocket.
(Ref. Surgery Sixer 3rd Edition Page 142)
175. Drug of Choice for Severe Mastitis? 
Types of Graft:  (Recent Pattern 2019 Question)
•• Allograft: An organ or tissue transplanted from one a. Cefphalosporins b. Augmentin
individual to another c. Cloxacillin d. Erythromycin
•• Isograft: Organs transplanted between identical twins
and are immunologically indistinguishable Ans.  (c) Cloxacillin
•• Autograft: Organ or tissue transplanted within same (Ref. Surgery Sixer 3rd Edition Page 268)
individual, e.g. skin graft, bone graft and free flap
•• MC organism causing Mastitis- Staphylococcus aureus
•• Xenograft: A graft performed between different species
•• Drug of Choice is- Cloxacillin
172. Most common indication for Liver Transplant in
176. What is the swelling shown here in Image? 
paediatric Patients:  (Recent Pattern 2019)
 (Recent Pattern 2019 Question)
a. Biliary Atresia
b. Cirrhosis
c. Hepatitis
d. Fulminant liver failure

Ans.  (a) Biliary Atresia

(Ref: Surgery Sixer 3rd Edition Page 153)
•• MC indication for Liver transplant in Children- Biliary
atresia
•• MC indication for Liver transplant in Adults – HCV
induced cirrhosis
•• MC metabolic indication for Liver transplant- Alpha 1
AT deficiency
173. Maintenance level of Mixed Venous Oxygen Saturation
in shock must be  (Recent Pattern 2019 Questions)
a. >70%. b. 50-70% a. Dermoid Cyst b. Sebaceous cyst
c. 40-50% d. < 40% c. Cysticercosis d. Meningioma

Ans.  (b) 50-70% Ans.  (b) Sebaceous Cyst

(Ref. Surgery Sixer 3rd Edition Page 8) (Ref. Surgery Sixer 3rd Edition Page 934)
•• Incomplete Question, they must have given some clue to
Mixed Venous Oxygen Saturation:
differentiate Sebaceous or Dermoid Cyst.
•• This is a measure of oxygen returning to heart from •• MC swelling in scalp is Sebaceous cyst. Let’s go with it.
body  after delivery and extraction by tissues. •• If swelling is given in Post auricular or External Angular
•• Normal Value- 50-70% region we might have gone with dermoid cyst.
•• In cardiogenic shock and Hypovolemic shock, the tissues
takes up more oxygen and hence value is low < 50%
•• In Septic and Distributive shock , the tissues takes up
less oxygen and hence more oxygenated blood returns
to heart and hence value is high > 70%

53
 Section A  Recent Questions 2019

177. What is the swelling shown in the Image?  •• All the above points suits for Pleomorphic adenoma.
 (Recent Pattern 2019 Question) •• Warthin’s tumor is common in lower pole of parotid at
angle of mandible.
•• Common things are common- hence go with
Pleomorphic adenoma**
179. A 14 week post natal woman presents with fluctuant
breast swelling ,what would be the treatment
 (Recent Pattern 2019 Question)
a. Incision and Drainage
b. Continue Breast feeding with antibiotics
c. Analgesics
d. Repeated Aspirations under antibiotic cover.

Ans.  (d) Repeated aspiration under antibiotic cover

(Ref: Bailey and Love 27th edition Page 866)
a. Branchial cyst b. Pharyngeal pouch •• The clinical diagnosis of a lactating mother at 14 weeks
c. Dermoid Cyst d. Pretracheal Bursa is usually a mastitis followed by Breast abscess. Abscess
presents with Fluctuant swelling
Ans.  (a) Branchial Cyst •• During cellulitis stage- only Antibiotic such as Flu
cloxacillin and Co amoxiclav can be used. Feeding can
Ref. Surgery Sixer 3rd Edition Page 210)
be given via the affected stage at this time. Analgesics
The swelling shown in the image is having following will help to relieve pain with support of breast.
features: •• In antibiotics alone used in the presence of underlying
•• Anterior Triangle swelling ( So pharyngeal pouch ruled pus- Antibioma will form.
out) •• Olden days- Incision and Drainage was advised if not
•• Not in midline ( Hence Dermoid cyst and Pretracheal resolves in 48 hours.
bursa ruled out) •• Latest recommendation: Repeated aspirations under
•• Only swelling which suits the location at upper 1/3rd antibiotic cover ( if needed under USG Guidance )to
level of Sternocleidomastoid muscle is Branchial cyst** be performed. This allows resolution without Incision
178. Identify the swelling having Variable Consistency with and Drainage and will also allow breast feeding in the
no pain:  (Recent Pattern 2019 Question) affected breast**
180. Retrosternal Goitre Approach is 
 (Recent Pattern 2019 Question)
a. Transthoracic 2nd ICS
b. Transthoracic 4th ICS
c. Trans sternal via Anterior mediastinum
d. Transcervical approach

Ans.  (d) Transcervical approach

(Ref: Surgery Sixer 3rd Edition Page 227)
•• Retrosternal goitre is 99% extension from Goitre in neck
due to enlargement. And such extended retrosternal
goitres are mostly removed by neck incision itself by
putting the fingers and hooking out the gland.
•• Such manoeuvre of removal via neck incision is known
a. Pleomorphic Adenoma
b. Warthin tumor as Toboggan Technique**.
c. Abscess parotid •• Very rarely Sternotomy is done if the goitre is primary
d. Parotid stone mediastinal goitre.
181. Frey’s Syndrome is due to injury of which of the following
Ans.  (a) Pleomorphic adenoma nerve branch?  (Recent Pattern 2019 Question)
(Ref. Surgery Sixer 3rd Edition Page 190) a. Trigeminal nerve
b. Vagus nerve
•• Yet another question without proper clue by NBE., but c. Facial Nerve
from the picture we can see- It’s having three salient d. Glossopharyngeal nerve
points:
ƒƒ Obliterates Retromandibular groove Ans.  (a) Trigeminal Nerve
ƒƒ Lifts Ear lobule
(Ref. Surgery Sixer 3rd Edition Page 191)
ƒƒ Painless

54
 Section A  Recent Questions 2019

•• Auriculo temporal nerve is the Post ganglionic margins (Punched out**) usually in upper half of
parasympathetic nerve which on injury during esophagus.
parotidectomy, results in Gustatory sweating syndrome
known as Frey’s syndrome after 2-3 months.
•• Auriculotemporal nerve is the branch of Mandibular
division of Trigeminal Nerve( 5th Cranial Nerve)
182. Frey’s Syndrome- False statement is 
 (Recent Pattern 2019 Question)
a. Auriculo temporal nerve carrying Post ganglionic
Sympathetic fibres is injured
b. Gustatory sweating
c. Botulinum Toxin injection is the treatment.
d. Less chances in Enucleation of lesion than in
parotidectomy.

Ans. (a) Auriculo Temporal nerve carrying Post

ganglionic Sympathetic Fibres is injured CMV Esophagitis:
(Ref. Surgery Sixer 3rd Edition Page 191) •• Seen in Graft versus host disease following BM
•• Frey’s Syndrome is due to the Parasympathetic post transplantation.
ganglionic nerve fibre injury. •• Endosocopy shows characteristic – Geographical or
•• It’s the Auriculotemporal nerve that carries them. Serpentine border**.
•• Recent Treatment is Injection of BOTOX in the
abnormally innervated areas.
•• There is less chance of this syndrome is the tumor alone
is enucleated than a superficial parotidectomy.

Section 3: Gastro Intestinal System and Hepato

Biliary System:
183. On endoscopy there is Serpiginous Ulcers in Distal
Esophagus with otherwise normal mucosa seen-
Diagnosis is  (Recent Pattern 2019 Exam)
a. Herpes Simplex b. Pill induced
c. CMV d. Candidiasis

Ans.  (c) CMV Fig.  Serpentine Lesion in Esophagus- CMV

•• In all the above cases- Endoscopic Biopsy is diagnostic.
(Ref: Bailey and Love 27th Edition Page 1104)
184. Punched out Ulcer in Esophagus on Endoscopy in a
•• A direct line from Bailey and Love 27th edition , from
Immunocompromised patient is seen in 
Esophageal infections:
 (Recent Pattern 2019 Exam)
Esophageal Infections: a. Herpes Zoster virus b. Herpes simplex
c. CMV d. Candidiasis
Candida Albicans Esophagitis:
•• MC in patients taking steroids ( especially transplant Ans.  (b) Herpes Simplex Virus  
recipients), Patients on Chemotherapy and Uncontrolled
(Ref. Bailey and Love 27th Edition Page 1104)
Diabetics.
•• It presents with Dysphagia or Odynophagia. 185. What is Dohlman’s Procedure in Zenker’s Diverticulum?
•• Endoscopy shows numerous white plaques which  (Recent Pattern 2019 Exam)
cannot be moved, unlike food particles. a. Endoscopic Stapling of Septum
•• Barium swallow shows- Dramatic mucosal ulceration b. Endoscopic Suturing of Pouch
resembling Esophageal varices ( Shaggy appearance on c. Resection of Pouch
Barium swallow) d. Laser excision
•• Treatment is with Topical Antifungal agent.
Ans.  (a) Endoscopic Stapling of septum
Herpes Simplex Esophagitis:
•• Common in Immunocompromised patients. (Ref. Surgery Sixer 3rd Edition Page 322)
•• Characterised by small raised herpetic vesicles few days •• Endoscopic Stapling Technique for Pharyngeal Pouch
before on the lips. (Zenker’s Diverticulum)is known as Dohlman’s
•• Endoscopy reveals- Vesicles and small ulcers with raised Procedure.

55
 Section A  Recent Questions 2019

186. Image of a patient with Pain abdomen, What will you do Ans.  (b) Acute Pancreatitis
next?  (Recent Pattern 2019 Exam)
(Ref. Surgery Sixer repeat Question Page 692)
Causes of Gasless Abdomen:
•• Mesentric Ischemia ( Ref. Schwartz Page 862)
•• Midgut Volvulus ( Ref. Sabiston Page 1872)
•• Acute Pancreatitis ( Ref. Surgery Sixer 3rd Edition Page
692)
Signs in X ray in Acute Pancreatitis:
•• Colon cut off
•• Sentinel Loop
•• Ground glass appearance
•• Renal halo sign
•• Gasless abdomen
188. Most common Morphological difference between
a. Emergency Laparotomy Ulcerative Colitis and Crohn’s disease: 
b. Conservative management  (Recent pattern 2019 Question)
c. Discharge him home a. Crypt abscess b. Diffuse polyps
d. Only IV fluids. c. Mucosal edema d. Lymphoid aggregates

Ans.  (a) Emergency Laparotomy Ans.  (a) Crypt abscess

(Ref. Surgery Sixer 3rd Edition Page 381) (Ref. Bailey and Love 27th Edition Page 1268 Table, Surgery
•• This is many times repeated Image- Air under diaphragm Sixer 3rd Edition page 429)
due to Duodenal Ulcer perforation. This question is asked based on a Table in Bailey and Love
•• Patient usually presents with perforation peritonitis. and same question is repeated in NEET SS exam also..
Management of Perforation Peritonitis ( Updated points Feature Ulcerative Colitis Crohn’s Disease
in 27th Edition Bailey Page 1126)
•• Initial Priority- Resuscitation and Analgesics. There is no Rectum Always involved Often Spared
contraindication to give analgesics with fear of masking Perianal lesions Rare Common
symptoms of peritonitis. Strictures in Bowel Rare Common
•• Following Resuscitation- Principal treatment is Surgical
by Upper Midline Laparotomy. Fistulas Rare Common
•• Laparoscopy can be used. Granulomas ABSENT** Common
•• Most important component in surgery- Thorough Fissures ABSENT** Common
Peritoneal Lavage to remove all fluid and food debris.
•• Options to close are: Crypt abscess Common ** Rare
ƒƒ Closed the perforated ulcer in transverse direction as •• The same question if had choice as granuloma, go with
in Pyloroplasty and then omental patch is kept. Don’t granuloma because very rarely Crypt abscess may be
tie sutures so tightly. seen in CD also.
ƒƒ If perforation is difficult to close primarily we can
189. Barret Esophagus – False statement is 
close the leak with omental patch alone ( Modified
 (Recent Pattern 2019 Question)
Graham’s Patch Closure) a. Hyperplastic change in the lining mucosa of esophagus
ƒƒ Gastric ulcers are excised and the edges closed to b. Goblet cells seen on histology
exclude malignancy. c. Patient is usually asymptomatic
ƒƒ Massive Duodenal or Gastric ulcers where closure is d. Chronic GERD is the predisposing factor
difficult we can do Distal Gastrectomy and do Roux
En Y reconstruction as procedure of Choice Ans. (a) Hyperplastic Change in lining mucosa of
•• All patients are given systemic antibiotics. esophagus
•• All patients are given Gastric antisecretory agents and
H.Pylori Eradication mandatory. (Ref. Surgery Sixer 3rd Edition Page 325, Bailey and Love 27th
•• Old concepts of Truncal vagotomy with Pyloroplasty or Edition Page 1081)
HSV are not done in most places now a days •• Barret’s Esophagus is a metaplasia of Squamous
187. Gasless abdomen in X ray seen in  Epithelium to Columnar Epithelium.
 (Recent Pattern 2019 Exam) •• Intestinal Goblet cells on Histology is classical finding.
a. Necrotising Enterocolitis •• GERD is a predisposing factor and they will be usually
b. Acute Pancreatitis asymptomatic and detected on endoscopy.
c. Ulcerative Colitis •• Strictures can occur in Barret’s and are always seen in
d. Intusussception Squamo columnar Junction**
•• Incidence of Cancer is 0.5% per patient per year.
56
 Section A  Recent Questions 2019

190. What is the image shown below?  Ans.  (a) Stress Ulcer in Head injury
 (Recent pattern 2019 Question)
(Ref. Surgery Sixer 3rd Edition Page 364)
•• Cushing ulcer: Ulcer in stomach in stress and head
injury (Most common site is body and fundus)
•• Curling ulcer: Ulcer in duodenum > Stomach in burns
•• Cameron ulcer: Ulcer in proximal stomach in hiatus
hernia (vertical ulcers also known as riding ulcers)
193. A patient with Acute pancreatitis admitted in ICU
suddenly develops – Tachypnea and respiratory distress.
Image of his X ray shown below: 
 (Recent Pattern 2019 Question)

a. Barium enema
b. Barium meal follow through
c. Enteroclysis
d. Barium meal

Ans.  (b) Barium meal follow through

(Ref. Surgery Sixer ditto repeat page 458)
•• Barium meal follow through is the investigation used to
study small bowel .
•• Barium meal follows through—patient swallows barium
as contrast mixed with water. What is your diagnosis?
•• X-ray is taken at serial interval times—half an hour, 1
a. Acute Respiratory Distress Syndrome
hour, 2 hours, 4 hours and 6 hours. b. Pleural Effusion
•• Enteroclysis is also a study of small bowel with Naso- c. Pulmonary Embolism
jejunal tubing in which contrast is pushed directly into d. Fat embolism
small intestine.
•• Enteroclysis is the best contrast imaging of small Ans.  (a) Acute Respiratory Distress Syndrome
bowel** which can be done by X-ray or CT enteroclysis
(Ref. Surgery Sixer 3rd Edition Page 678)
191. Teduglutide is a recently introduced drug for Short
Bowel Syndrome- What is it?  •• This is the image of ARDD showing Diffuse alveolar
 (Recent pattern 2019 Question) interstitial shadowing in Acute pancreatitis.
a. GLP- 2 analogue b. GLP anta agonist •• It is a dangerous complication in Acute pancreatitis.
c. Somatostatin analogue d. H1 blocker 194. Which of the following is False about Chronic Liver
disease patient  (Recent Pattern 2019 Question)
Ans.  (a) GLP -2 analogue a. MELD used for Liver transplant
(Ref. Surgery Sixer 3rd Edition Page 425, Direct line ) b. MELD has PT, INR, Albumin and Creatinine
c. CTP score has INR, Albumin and Bilirubin
Teduglutide: GLP-2 Analogue: d. CTP has Grades A,B and C
•• Randomized controlled trials have shown that
teduglutide, a GLP-2 analogue that is resistant to Ans.  (b) MELD has PT, INR, Albumin and Creatinine
degradation by the proteolytic enzyme dipeptidyl (Ref: Surgery Sixer 3rd Edition Page 630)
peptidase 4 and therefore has a longer half-life than
GLP-2, is well tolerated and has led to the restoration MELD: Modified End Liver Disease Scoring:
of intestinal functional and structural integrity through •• Based on :”CBI” - Creatinine, Bilirubin, INR
significant intestinotrophic and pro absorptive effects. •• Recently Waiting list for transplant is made on the basis
192. Cushing Ulcer seen in  (Recent Pattern 2019 Question) of MELD score*
a. Stress ulcer in Head injury •• Initially MELD score was used to predict mortality after
b. Stress ulcer in Burns TIPSS , but now used for Transplant cases.
c. Ulcer in Hiatus hernia •• Values vary from 6-40*
d. Ulcer in Crohn’s disease •• Liver transplant is allowed only for MELD > 15**
Child Pugh Score: is calculated  by BANIA- Bilirubin,
Albumin, Nutrition, INR and Ascites

57
 Section A  Recent Questions 2019

195. Identify the triangle shown in the image:  •• The treatment of choice is medical- oral prednisolone
 (Recent pattern Question 2019) 1mg/kg produces dramatic response in 50–70% cases.
•• Intravenous immunoglobin is indicated for internal
bleeding.
Refractory ITP
•• Failure of initial therapy mentioned above.
•• Rituximab **given IV
•• Thromboplastin Receptor antagonists- Eltrombopag
and Romiplostim**
Splenectomy
•• Most common indication for elective splenectomy
•• For patients with low platelet count should have platelets
available at surgery but should be infused only after
ligating the pedicle**.
•• Should not be given preoperatively
a. Calot’s triangle
b. Hepatocystic Triangle 198. Cholesterol Stone made up of  (Recent Pattern 2019 )
c. Gastrinoma Triangle a. Amorphous Cholesterol Monohydrate
d. Doom triangle b. Crystalline Cholesterol Monohydrate
c. Cholesterol Polyhydrate
Ans.  (c) Gastrinoma triangle d. Cholesterol with Calcium Palmitate
(Ref. Surgery Sixer Page 684) Ans.  (b) Crystalline Cholesterol Monohydrate
Gastrinoma Triangle or Passaro Triangle: (Ref. Bailey and Love 27th Edition Page 1198, Surgery Sixer
•• About 70-90% will be located in this triangle: 3rd Edition Page 579)
•• Junction of CBD and cystic duct
•• Junction of neck and body of pancreas Composition of Each Stones:
•• Junction of 2nd and 3rd part duodenum
Cholesterol Stones:
196. Cholecysto-caval line importance •• Cholesterol Stones are formed by Nucleation of
 (Recent pattern Question 2019) Cholesterol Monohydrate crystals from multilamellar
a. Line that divides the Right and left liver surgical anatomy vesicles.
wise •• MC type of Gall stone in Western Countries
b. Line that divides Right liver into anterior and posterior
segments Pigment Stones:
c. Line that divides the Left liver into medial and lateral •• Contains < 30% Cholesterol
segments •• Brown Pigment Stone- Composed of Calcium
d. Line that runs along the Portal vein. Bilirubinate, Calcium Palmitate and Calcium Stearate as
well as Cholesterol.
Ans.  (a) Line that divides the right and left liver surgical •• Black Pigment Stone- Composed of Largely Insoluble
anatomy wise Bilirubin pigment Polymer mixed with Calcium
(Ref. Surgery Sixer 3rd Edition Page 628) Phosphate and Calcium Bicarbonate*

•• Cholecystocaval line also known as Cantle’s line is an Speciality Surgeries

imaginary line running from Gallbladder fossa to left
side of IVC. 199. A patient complaints of breathlessness following a
•• It’s an imaginary line that is drawn by Coiunaud for trauma, Trachea shifted to opposite side, Resonant
surgically dividing the liver into Right and left liver. percussion note seen with absent Breath sounds. On
•• Middle hepatic vein runs on this line. insertion of ICD- False statement is 
 (Recent Pattern 2019 Question)
197. What is the treatment of Choice for Idiopathic
a. Done in Upper part of Lower Rib to avoid vessel and
Thrombocytopenic Purpura?  nerve injury
 (Recent pattern 2019 Question) b. Direction of insertion in posterior and superior
a. Blood transfusion b. Steroids c. Inserted into the 4th or 5th ICS along the scapular line
c. IV immunoglobin d. Splenectomy d. Insertion area must be palpated digitally to confirm the
position
Ans.  (b) Steroids
(Ref: Surgery Sixer 3rd Edition page 724) Ans.  (c) Inserted into 4th or 5th ICS along the Scapular
Line
Medical Treatment of ITP
(Ref. Surgery Sixer 3rd Edition Page 95, Bailey and Love 27th
Edition Page 920)

58
 Section A  Recent Questions 2019

Inserting a Chest Drain: (Latest Bailey and Love 27 th •• Ad- Deep Veins
Edition Update) •• An- No venous Location identified
Pathological Classification:
Site of Insertion:
•• Pr- Reflux
•• Triangle of Safety Boundaries:
•• Po- Obstruction
•• Anterior to mid axillary line
•• Pr, o- Reflux and Obstruction
•• Above level of nipple
•• Pn- No Venous Pathology identifiable
•• Below and Lateral to Pectoralis Major
•• This usually gets inserted in 5th ICS level. 201. Identify the image shown below (Recent pattern 2019)
Steps in ICD Insertion:
•• Meticulous Sterility maintained.
•• Insert Local Anaesthesia up to Pleura.
•• Sharp dissection to Cut only the Skin.
•• Blunt Dissection using Artery Forceps through the
muscles- Intercostal and Serratus anterior.
•• Oblique tract is made so that the parietal pleura is
tunnelled to avoid leakage of air.
•• Drain in cases of Haemothorax and Pneumothorax
should aim the Apex**
•• Drain for Empyema and Pleural effusion should be at
Base**
•• Drain should pass at the upper edge of the rib to avoid
injury to neurovascular bundle.
•• Don’t apply any clamp in Drain as it may be forgotten to
be removed.
•• Don’t apply suction also.
•• Bubbling drain must never be clamped. a. Ureterocele b. Ureteric Stone
•• Check the drain location by a Chest X ray. c. Vesico Ureteric Reflux d. PUJ obstruction
200. A patient presents with heaviness of leg with veins of Ans.  (a) Ureterocele
diameter less than 1mm over the posterior part of the
calf- Under CEAP , classification it comes under  (Ref. Surgery Sixer 3rd Edition Page 749)
 (Recent Pattern 2019) •• Ureterocele shows Characteristic Adder head ( Cobra
a. C1 b. C2 head) appearance on IVP.
c. C3 d. C0 202. Omphalocele is caused by  (Recent Pattern 2019 )
a. Duplication of Intestinal loops
Ans.  (a) C1 b. Abnormal rotation of the intestinal loop
(Ref. Surgery Sixer 3rd Edition Page 885) c. Failure of GUT to return to the body cavity from its
physiological herniation
CEAP Classification: d. Reversed rotation of intestinal loop
Clinical Classification: Ans.  (c) Failure of GUT to return to Body cavity from its
•• C0- No signs of Venous Disease physiological herniation
•• C1- Telangiectasia ( <1mm Diameter)/ Reticular Veins
(Ref: Sabiston 20th edition Page 1071)
(1-2.9 mm Diameter)
•• C2- Varicose Vein ( > 3 mm Diameter) •• There are two abdominal wall defects due to failure of
•• C3- Oedema development of abdominal musculature:
•• C4- Pigmentation, Eczema, Lipodermatosclerosis Omphalocele Gastroschisis
•• C5- Healed Venous Ulcer
Failure of GUT to return Similar disorder in
•• C6- Active Venous Ulcer
to body cavity from its which the umbilcal
Add S for Symptomatic and A for Asymptomatic cases
physiological herniation membrane has ruptures
Etiological Classification: with intact peritoneum and in utero allowing
•• Ec- Congenital Superficial amnion covering intestine to get exposed
•• Ep- Primary with no skin** outside.
•• Es- Secondary
50-60% of these babies Risk of mesenteric
•• En- No Venous Cause identified
have associated anomalies volvulus is seen as the
Anatomical Classification: like Skeletal, GIT, Cardiac, intestine has not yet
•• As- Superficial veins genitourinary anomalies completed rotation.
•• Ap- Perforator veins

59
 Section A  Recent Questions 2019

203. Degloving injury is characterised by  Ans.  (c) Median Lobe

 (Recent Pattern 2019)
(Ref. Internet Sources)
a. Loss of Skin only
b. Loss of Skin and Subcutaneous tissue with intact fascia •• Uvula Vesica is a small elevation in the mucous
c. Loss of Skin and Subcutaneous tissue along with Fascia membrane immediately above and behind the internal
d. Loss of Skin, Subcutaneous Tissue and Muscle. urethral orifice.
•• Produced by median Lobe*
Ans. (b) Loss of Skin and Subcutaneous Tissue with •• During BPH – this Uvula vesicae is also enlarged.
Intact Fascia
(Ref. Surgery Sixer 3rd Edition Page 66, Bailey and Love 27th
PEDIATRICS
Edition Page 27)
Degloving Injury is defined as an Avulsion injury including 206. Bidextrous grip is seen at what age?
the following layers: a. 4 months b. 5 months
•• Skin c. 6 months d. 7 months
•• Subcutaneous Tissue
Please remember the degloving injury is above the Fascia( Ans. (a)  4 Months
Leaving Intact Fascia) exposing the Neurovascular
structures, Tendon and Bone. Explanations given in May AIIMS paper
It can be open or closed also. 207. Which vaccine to be given every year ?
204. False about Deep Vein thrombosis is  a. Hepatitis A b. Pneumococcal
 (Recent Pattern 2019 Question) c. Influenza d. Chicken pox
a. Leg pain is most common symptom
b. Bilateral DVT is common Ans.  (c) Influenza
c. Some People present 1st time with Pulmonary embolism
d. Clinical Evaluation is most reliable Explanations given in May AIIMS paper
208. APGAR score 3 at 1 minute indicates:
Ans.  (d) Clinical Evaluation is most reliable a. Mildly depressed
(Ref. Surgery Sixer 3rd Edition Page 888, Bailey and Love 27th b. Further resuscitation not needed
Edition Page 987, 988 Line by line) c. Severely depressed
d. Normal
•• MC presentation of DVT is Pain and swelling especially
in calf. Ans.  (c) Severely depressed
•• Usually involves one leg only (Bilateral can happen in
30%) Explanations given in DNB June paper
•• Some patients with no symptoms of DVT can present 1st 209. Severe acute malnutrition as per who criteria-
time with signs of Pulmonary embolism Eg.Chest pain, a. Weight for age less than median plus – 2 SD
Hemoptysis, Shortness of Breath. b. Weight for height less than median plus 2 SD
•• Clinical Examination is unreliable. Physical signs may c. Weight for age less than median plus 3 SD
also be absent. d. Weight for height less than median minus -3SD
•• Leg pain occurs in 50% and non-specific.
•• Pain and tenderness associated with DVT does not Ans.  (d) Weight for height less than median minus -3SD
usually correlate with size, Location or Extent of the Ref: Nelson 20th edition page 301,302
Thrombus. •• Definition of severe acute malnutrition - severe wasting
•• Clinical signs and Symptoms of Pulmonary Embolus and/or bilateral edema
occur in about 10% of patients with Confirmed DVT* •• Severe wasting is weight for length (or height) that is
•• The probability of developing Pulmonary embolus is below -3SD of the WHO Child Growth Standards.
given by a criteria known as Modified Wells Criteria** •• Diagnosis of bilateral edema - by grasping both feet,
205. Uvula vesicae is produced by which prostate lobe placing a thumb on top of each, and pressing gently but
 (Recent Pattern 2019 Question) firmly for 10 seconds. A pit that stays under each thumb
a. Anterior lobe b. Posterior lobe denotes bilateral edema
c. Median lobe d. Lateral lobe

60
 Section A  Recent Questions 2019

Site Signs
Face Moon face (kwashiorkor), simian facies (marasmus)
Eye Dry eyes, pale conjunctiva, Bitot spots (vitamin A), periorbital edema
Mouth Angular stomatitis, cheilitis, glossitis, spongy bleeding gums (vitamin C), parotid enlargement
Hair Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating bands of light and normal color),
broomstick eyelashes, alopecia
Skin Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry, follicular hyperkeratosis,
patchy hyper- and hypopigmentation (crazy paving or flaky paint dermatoses), erosions, poor wound
healing
Teeth Enamel mottling, delayed eruption
Nails Koilonychia, thin and soft nail plates, fissures, or ridges
Musculature Muscle wasting, particularly buttocks and thighs; Chvostek or Trousseau sign (hypocalcemia)
Skeletal Deformities, usually as a result of calcium, vitamin D, or vitamin C deficiencies
Abdomen Distended: hepatomegaly with fatty liver; ascites may be present
Neurologic Global developmental delay, loss of knee and ankle reflexes, impaired memory
Cardiovascular Bradycardia, hypotension, reduced cardiac output, small vessel vasculopathy
Hematologic Pallor, petechiae, bleeding diathesis
Behavior Lethargic, apathetic, irritable on handling

Stabilization Rehabilitation
Day 1-2 Day 3-7 Week 2-6
1. Prevent/treat hypoglycemia
2. Prevent/treat hypothermia
3. Treat/prevent dehydration
4. Correct imbalance of electrolytes
5. Treat infection
6. Correct deficiencies of micronutrients no iron with iron
7. Start cautious feeding
8. Rebuild wasted tissue (Catch-up growth)
9. Provide loving care and play
10. Prepare for follow-up

Management of SAM 210. Where to look for pre-ductal O2 saturation in PDA in a 3

minute born infant?
Also Remember a. Fetal left Upper limb b. Fetal left lower limb
c. Fetal right Upper limb d. Fetal right lower limb
Antibiotics recommended in SAM
Ans.  (c) Fetal right Upper limb
If no complications Amoxicillin oral 25 mg/kg
twice daily for 5 days Re f :https ://www.ncbi.nlm.nih.g ov/pmc/ar ticles/
PMC2879243/Christoph Rüegger, Hans Ulrich Bucher, and
If complications Gentamicin (7.5 mg/kg
Romaine Arlettaz Mieth
(shock, hypoglycemia, IV or IM) once daily for 7
hypothermia, skin lesions, days and •• Preductal oxygen saturation is always recorded on
respiratory or urinary tract Ampicillin (50 mg/kg IV or right upper limb. The left hand, however, has always
infections, or lethargy/ IM) every been ignored, as it was unclear if the ductus arteriosus
sickly) influences left-hand arterial perfusion.

61
 Section A  Recent Questions 2019

211. True about Fragile X syndrome is- Ans.  (d) Hypokalemia

a. Triple nucleotide CAG Sequence mutation
Ref: Nelson 20th Edition Page 870,871
b. 10% Female carriers mentally retarded
c. Males have iq 20-40 •• Most common life-threatening emergency of the
d. Gain of function mutation gastrointestinal tract in the newborn period
•• The distal part of the ileum and the proximal segment of
Ans.  (c) Males have iq 20-40 colon are involved most frequently
•• The greatest risk factor for NEC is prematurity. NEC can
Ref: Nelson 20th edition page 622,623
occur secondary to birth asphyxia, Down syndrome,
Fragile X Syndrome: congenital heart disease, rotavirus infections, and
•• Fragile sites also have a role in tumorigenesis. CGG Hirschsprung disease, red cells transfusion
repeat expansion silences the gene responsible for •• Coagulation necrosis is the characteristic histologic
fragile X mental retardation protein (FMRP) which finding in intestinal specimen.
regulates the translation of multiple mRNA’s to specific •• Common pathogens causing NNEC include Escherichia
proteins, hence it affects the synaptic function. coli, Klebsiella, Clostridium perfringens, Staphylococcus
•• Lack of this FMRP protein upregulates the metabotropic epidermidis, astrovirus, norovirus, and rotavirus.
glutamate receptor % pathway. •• Aggressive enteral feeding may predispose to the
•• Lack of FMEP also affects the expression of matrix development of NEC
metalloproteinase •• The onset of NEC is usually in the 2nd or 3rd wk of life
but can be as late as 3 months in VLBW infants.
Clinical Manifestations in Affected Males are
•• Pneumatosis intestinalis (air in the bowel wall) is
•• intellectual disability, diagnostic
•• autistic behavior,
•• macroorchidism(may not be evident until puberty) Triad of Necrotising Enterocolitis Includes:
•• hyperextensible finger joints, and •• Thrombocytopenia
•• characteristic facial features long face, large ears, and a •• Metabolic Acidosis
prominent square jaw •• Refractory Hyponatremia
•• Connective tissue abnormalities: mitral valve prolapse,
scoliosis, joint laxity, flat feet Also Remember
•• Others: seizures (20%), recurrent otitis media (60%),
•• BELLS STAGING CRITERIA is applied for necrotizing
strabismus (8-30%)
enterocolitis
•• Developmental delay- mean IQ = 42 in Males;
ƒƒ IQ is higher if significant residual FMRP is produced
(e.g., females and mosaic males or unmethylated full
mutations)
OBG
•• Autism 20-30%
213. Gestational Trophoblastic neoplasm does not include:
•• ADHD 80%
a. Choriocarcinoma
•• Anxiety 70-100%
b. Placental site trophoblastic tumour
c. Invasive mole
Also Remember d. Partial mole
•• The larger the triplet repeat expansion, the more significant
Ans.  (d) Partial mole
the intellectual disability.
•• Males with premutation triple repeat expansions (50-200 Ref: Williams gynecology 3rd Edition Pg No: 785
repeats), have been found to have an adult, late onset Gestational trophoblastic neoplasia: includes
progressive neurodegenerative disorder known as fragile •• Choriocarcinoma- mostly develops after molar
X-associated tremor/ataxia syndrome gestation.
•• Invasive mole- exclusively develops after molar
Treatment
gestation
•• Minocycline (lowers MMP9) has resulted in short term •• Placental site trophoblastic tumor- mostly develop
improvements in anxiety, mood, and the clinical Global following a term gestation
Impression Scale. •• Epitheloid trophoblastic tumor- rarest
•• M-gluR antanogists under trial
214. Which vaccine is contraindicated in pregnancy :
212. Which among the following is not included in the triad of a. Chicken pox b. Rabies
necrotizing enterocolitis? c. Tetanus toxoid d
. Hepatitis B
a. Thrombocytopenia
b. Metabolic acidosis Ans.  (a) Chicken pox
c. Hyponatremia
Ref: Williams obstetrics 25th Edition Pg No:10/34
d. Hypokalemia

62
 Section A  Recent Questions 2019

215. 45 years female with 3 months menorrhagia. USG

Vaccine Before During After
pregnancy pregnancy pregnancy showing 2 cm submucosal fibroid. First line of
management is:
Hepatitis A If indicated a. Ocp for 3 months
Hepatitis B b. Progesterone for 3 months
c. Endometrial sampling
HPV vaccine 9-26 years Not indicated 9-26 years
d. Hysterectomy
Influenza (live avoid contraindicated avoid
attenuated) conception conception for Ans.  (c) Endometrial sampling.
for 4 weeks 4 weeks
Ref: Williams gynecology 3rd Edition Pg No:184
MMR avoid contraindicated give •• American College of Obstetricians and Gynecologists
conception postpartum if recommends endometrial assessment in any woman
for 4 weeks susceptible to older than 45 years with AUB, and in those younger than
rubella 45 years with a history of unopposed estrogen exposure
Meningococcal if indicated such as seen in obesity or polycystic ovarian syndrome
Pneumococcal (PCOS), failed medical management, and persistent
AUB.
Varicella avoid contraindicated give •• Then management is done accordingly depending upon
conception postpartum if HPE report.
for 4 weeks susceptible
216. In low ovarian reserve,anti mullerian hormone level will
Tetanus, If never Each pregnancy If never given be
diphtheria, given between 27-36 previously a. <1 b. 1-4
pertussis previously weeks c. >7 d. >10
Rabies Considered safe
if needed Ans.  (a) <1
Ref: Williams gynecology 3rd Edition Pg No:436
Immunization during Pregnancy:
•• AMH levels in mature women reflect ovarian follicle
•• Live virus vaccines-Contraindicated during
reserve
pregnancy:
•• Expressed by the granulosa cells of small preantral
ƒƒ MMR
follicles
ƒƒ Varicella
•• Vary minimally across the cycle
ƒƒ OPV
•• 3 ng/mL at age 25, and this dropped to 1 ng/mL at age
ƒƒ Yellow fever
35 to 37.
ƒƒ Pneumococcal
•• In case of low ovarian reserve- levels are <1 ng/ml
ƒƒ Influenza (live attenuated)
•• Vaccines safe during pregnancy: 217. Presenting diameter of full flexed head:
ƒƒ DT a. Suboccipito-bregmatic diameter
ƒƒ Hepatitis B b. Suboccipito-frontal diameter
ƒƒ Rabies- inactivated one c. Occipito-frontal diameter
ƒƒ Influenza (inactivated) d. Occipito-posterior position
ƒƒ TT
Ans.  (a) Suboccipito-bregmatic diameter
Ref: DC Dutta obs 7th Edition Pg No:85

Presentation Attitude Engaging diameter Denominator

Vertex Complete flexion Suboccipitobregmatic (9.5cm) Occiput
Occipitoposterior Deflexion Occipitofrontal (11.5cm) Occiput
Brow Partial extension Mentovertical (14cm) Frontum
Face Complete extension Submentobregmatic (9.5cm) Mentum

218. What is the dose of ulipristal acetate:

a. 300mg b. 30mg
c. 300µg d. 30µg

Ans.  (b) 30mg

Ref: Williams gynecology 3rd Edition Pg No:131

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 Section A  Recent Questions 2019

Methods available for use as emergency contraception

Method Formulation Pills per dose
Progesterone only pill
Plan B 0.75mg levonorgestrel 1 (2 doses 12 hours apart within 72 hours
of intercourse but may be upto 120 hours)
Plan B one step 1.5 mg levonorgestrel 1 (single dose within 72 hours)
Selective progestin receptor modulator pills (SPRM pills)
Ella 30mg ullipristal acetate 1 (taken upto 120 hours)
COC pills
Ogestrel, ovral 0.05mg ethinyl estradiol +0.5mg norgestrel 2
YUZPE regimen 0.1mg ethinyl estradiol+0.5mg 1 (2 doses 12 hours apart within 72 hours
levonorgestrel of intercourse but may be upto 120 hours)
Antiprogesterone
Mifepristone 100mg 1 (single dose within 17 days of
intercourse)
Copper-containing IUCD
Paragard T 380A Within 5 days of intercourse

219. The major contribution of the amniotic fluid after 20 221. First line of treatment of mastitis in a lactating mother is:
weeks of gestation : a. Cloxacillin b. Cefazolin
a. Ultrafiltrate and maternal plasma c. Ceftriaxone d. Ampicillin
b. Fetal urine
c. Fetal lung fluid Ans.  (a) Cloxacillin
d. Fetal skin Ref: Williams obstetrics 25th Edition Pg No:4/22
Ans.  (b) Fetal urine Mastitis:
Ref: Mudaliar and Menon’s 12 Edition Pg No: 28.
th •• Infection of mammary parenchyma
•• Common in lactating women
Amniotic fluid: •• MC organism- staph aureus
•• First line management- Dicloxacillin, 500 mg orally four
•• pH = 7.1 -7.3
times daily
•• Specific gravity= 1.008-1.010
•• If penicillin sensitive- erythromycin
•• Osmolality = 250 mOsm/L
•• Rate of amniotic fluid turnover is 500cc/hr 222. Patient with recurrent abortion diagnosed to have
•• Completely changed and replaced in every 3 hours antiphospholipid syndrome. What will be the treatment:
•• Main source- fetal urine (overall) a. Aspirin only
•• Main source after 20 weeks- fetal urine b. Aspirin + Low molecular weight Heparin
c. Aspirin + Low molecular weight Heparin + Prednisolone
220. Nuchal translucency in USG can be detected at_____wks
d. No Treatment
of gestation.
a. 11-13 wks b. 18-20 wks Ans.  (b) Aspirin + Low molecular weight Heparin
c. 8-10 wks d. 20-22 wks
Ref: Williams obstetrics 25th Edition Pg No:18/53
Ans.  (a) 11-13 wks
Antiphosholipid Antiboby Syndrome:
Ref: Williams obstetrics 25th Edition Pg No:4/73 Prothrombotic disorder can affect both the venous and
Nuchal Transluceny: arterial circulations
Criteria include:
•• Component of first trimester aneuploidy screening
•• at least one otherwise unexplained fetal death at or
•• Maximum thickness of the subcutaneous translucent
beyond 10 weeks
area between the skin and soft tissue overlying the fetal
•• at least one preterm birth before 34 weeks’ gestation
spine at the back of the neck.
because of eclampsia, severe preeclampsia, or placental
•• Measured between 11-14 weeks
insufficiency

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 Section A  Recent Questions 2019

•• at least three unexplained consecutive spontaneous 224. 30 year old woman with complaint of dysmenorrhoea,
abortions before 10 weeks. dyspareunia with chronic pelvic pain undergoes
Patients should be tested for the presence of three factors: hysterectomy. From the cut section of hysterectomy
•• Lupus anticoagulant specimen below identify the condition.
•• Anticardiolipin immunoglobulin G and M (IgG and IgM)
antibodies
•• Anti-β2-glycoprotein I IgG and IgM antibodies.
Management: aspirin plus prophylactic anticoagulation
with heparin throughout pregnancy and then for 6
weeks postpartum with either heparin or warfarin is
recommended
223. Identify the type of placenta praevia as shown in the
picture below?

a. Adenomyosis b. Fibroids
c. Leiomyoma d. Endometriosis

Ans.  (a) Adenomyosis

Ref: Shaw’s text book of Gynaecology, 16th Edition Pg No:420

Adenomyosis:
•• uterine endometriosis
•• observed frequently in elderly women
a. I. b. II. •• symmetrically enlarged around 14 weeks
c. III. d. IV. •• cut section shows: diffuse thickening of myometrium
alongwith multiple tiny dark areas of hemorrhages
Ans.  (b) II
225. 60 year woman comes with 3rd  degree uterine prolapse.
Ref: DC Dutta obs 7th Edition Pg No:242 What will be the management?
a. Vaginal hysterectomy with pelvic floor repair
Placenta previa: b. Pelvic floor repair
•• When the placenta is implanted partially or completely c. Sacrospinous fixation
over the lower uterine segment d. Pessary
•• Degree:
ƒƒ Type I- low lying Ans.  (a) Vaginal hysterectomy with pelvic floor repair
ƒƒ Type II- marginal Ref: DC Dutta obs 7th Edition Pg No:211
ƒƒ Type III- partial/ incomplete
Types of prolapse and the common surgical repair
ƒƒ Type IV- complete placenta previa/ Central / Total
procedures:

Vaginal wall Anterior wall Cystocoel/cystourethrocoel Anterior colporrhaphy

Paravaginal defect Paravaginal defect repair
Posterior (lower 2/3) Rectocoel Colpoperineorrhaphy
Posterior (upper 1/3) Enterocoel Vaginal repair of enterocoel with PFR
Mccall culdoplasty
Moscowitch procedure
Anterior+ posterior Cystocoel+rectocoel Pelvic floor repair
Uterovaginal Uterus+vaginal walls Uterovaginal prolapse Ward mayos procedure(vaginal
hysterectomy)
Fothergill operation (preservation of
uterus)
Contd…

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 Section A  Recent Questions 2019

Vaginal Vaginal wall Vault prolapse Vaginal: sacrospinous colpopexy,

(following hysterectomy) colpcleisis (le fort)
Abdominal: sacral colpopexy
Uterus Without vaginal wall Congenital/nulliparous prolapse Cervicopexy,
Sling(purandare) operation

As the patient is 60 years old and with uterovaginal prolapse- best management is ward mayo’s vaginal hysterectomy with pelvic
floor repair.
226. Day 20 of menstrual cycle falls under which phase?
a. Menstrual phase b. Follicular phase
c. Ovulation phase d. Luteal phase

Ans.  (d) Luteal phase

Ref: Shaw’s text book of Gynaecology, 16th Edition Pg No:43

Menstrual cycle Follicular phase/ proliferative phase Luteal phase/ secretory phase
Days 1-14 14-28
Main hormone Estrogen Progesterone
Cervical mucus Abundant mucus thin, viscous, penetrable to Thick, tenacious, impermeable to sperms
sperms
Vagina Superficial cells with glycogen Intermediate cells
227. Chromosome number of partial hydatidiform mole is-
a. 46 XX b. 45 XO
c. 46 XXY d. 69 XXX

Ans.  (d) 69 XXX

Ref: Williams obstetrics 25th Edition Pg No:5/15
Features of complete and partial mole:
Feature Partial mole Complete mole
Karyotype 69XXX or XXY 46XX
Clinical presentation
Preliminary diagnosis Missed abortion Molar gestation
Uterine size Small for dates Large for dates
Theca lutein cyst Rare 25-30% cases
Initial HCG levels <1,00,000 mIU/ml >1,00,000 mIU/ml
Medical complication Rare Uncommon
Rate of subsequent GTN 1-5% 15-20%
Pathology
Embryo fetus Often present Absent
Amnion, fetal erythrocyte Often present Absent
Villous edema Focal Widespread
Trophoblastic proliferation Focal, slight to moderate Slight to severe
Trophoblast atypia Mild Marked
P57KIP2 immunostaining Positive negative
Pathogenesis
2 paternal haploid sets and 1 maternal •• Duplication of single sperm genome and
haploid set inactivation of egg genome
•• Fusion of 2 different sperms with egg
whose genes have been inactivated
Contd…

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 Section A  Recent Questions 2019

Chromosomes Both paternal and maternal origin Entirely paternal origin

Complications
•• Thyrotoxicosis Less common/rare More common/ severe
•• Hyperemesis gravidarum
•• Preeclampsia
Investigation of choice USG (multicystic placenta) USG (snowstorm appearance)
(mimics incomplete or missed abortion)
Gold standard Histopathological examination Histopathological examination
(villi present) (villi absent)
Follow up investigation Beta HCG Beta HCG
Management Suction evacuation Suction evacuation

228. Vulvar atrophy and itching are treated by: 230. In 34 weeks gestation the weight of baby was 3kg.The
a. Estrogen ointment child shows following features may indicate associated
b. Antihistamines condition
c. Tamoxifen
d. None

Ans.  (a) Estrogen ointment

Ref: Williams gynecology 3rd Edition Pg No:263
Vaginal atrophy:
•• Mainly related to menopause
•• Cause itching, dyspareunia, rarely bleeding
Management by – local estrogen cream, selective estrogen
receptor modulator
a. Anemia b. Diabetes
229. PGF2 alpha maximum dose in PPH is-
c. APH d. None
a. 2000 μg b. 200 μg
c. 2 mg d. 20 mg Ans.  (b) Diabetes
Ans.  (c) 2 mg Ref: Williams obstetrics 25th Edition Pg No:19/30
Ref: Williams obstetrics 25th Edition Pg No:4/86 Diabetic mother and macrosomia:
Macrosomia defined as excessively large bay (>4kg)
According to ACOG- PPH is defined as cumulative
Causes are:
loss >1000ml accompanied by signs and symptoms of
•• Obesity
hypovolemia.
•• Poorly controlled maternal diabetes and gestational
Hemostasis after placental seperation-
diabetes
•• Myometrial contraction (1st step)
•• Postmaturity
•• Clotting
•• Multiparity
MC cause of PPH- atonic >>> traumatic
•• Male fetus.
Drug of choice- oxytocin
In diabetes: Excessive glycemia produce macrosomia due
•• Action start- 1 min
to insulin and insulin like growth factors.
•• T1/2- 3-5 min
Indication of cesarian section:
•• Dose- 20 units per litre of infusate @ 10-20ml/min
•• >4.5 kg in case of diabetic mother
2nd drug of choice- prostaglandins
•• >5 kg in case of non diabetic mother
•• PGE1 analogue (misoprost)
ƒƒ For prophylaxis- 600mcg 231. Which of the following is false as physiological change
ƒƒ For treatment- 1000mcg in pregnancy?
•• PGF2 alpha (carboprost) a. Increase cardiac output
ƒƒ Dose- 250mcg intramuscularly , maximum upto 8 b. Increase total protein
doses at an interval of 15-90 minutes. c. Increase residual volume
d. Increase GFR

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 Section A  Recent Questions 2019

Ans.  (c) Increase residual volume 232. Overt gestational diabetes is defined as random blood
glucose more than_?
Ref: Williams obstetrics 25 Edition Pg No:22/44
th
a. >200 mg/dl b. >126 mg/dl
Cardiovascular system c. >100 mg/dl d. >180 mg/dl

Increase Decrease Unchanged Ans.  (a) >200 mg/dl

Cardiac output Systemic vascular Antecubital Ref: Williams obstetrics 25th Edition Pg No:4/35
resistance venous pressure Overt diabetes is diagnosed as:
Stroke volume Diastolic blood CVP •• Random plasma glucose level >200 mg/dL plus classic
pressure signs and symptoms such as polydipsia, polyuria, and
unexplained weight loss
Heart rate Mean arterial PCWP
•• Fasting glucose level >125 mg/dL
pressure
•• Plasma glucose level >200 mg/dL measured 2 hours a er
Femoral venous a 75 g oral glucose load (diagnostic)
pressure 233. MgSO4 have no role in prevention of-
a. Seizures in severe pre-eclampsia
Respiratory System
b. Recurrent seizures in eclampsia
Increase Decrease Unchanged c. RDS in premature baby
d. Neuroprotection
Subcostal angle Expiratory reserve Total lung
volume capacity Ans.  (c) RDS in premature baby
Transverse Residual volume Respiratory
Ref: Williams obstetrics 25th Edition Pg No:38/68
diameter rate
Magnesium sulphate:
Chest Functional residual
Mechanism of action:
circumference capacity
•• Reduced presynaptic release of the neurotransmitter
Vital capacity Chest wall compliance glutamate
Inspiratory capacity •• Blockade of glutaminergic n-methyl-d-aspartate (nmda)
receptor
Tidal volume •• Potentiation of adenosine action
Minute ventilation •• Improved calcium buffering by mitochondria
•• Blockage of calcium entry via voltage-gated channels
Urinary System
Used for:
Increase Decrease •• Severe preeclampsia
•• Recurrent eclamptic seizures
Renal plasma flow Creatinine, uric acid
•• Neuroprotection
GFR Blood urea nitrogen Must check:
•• Urine output
Proteins: •• Respiratory rate
•• Patellar reflexes
Increase Decrease
234. Green frothy vaginal discharge is produced by –
Total plasma protein Plasma protein a. Herpes simplex
concentration b. Candida albicans
Globulin Albumin c. Trichomonas vaginalis
d. Normal vaginal flora
Albumin: Globulin
Ans.  (c) Trichomonas vaginalis
Ref: Williams gynecology 3rd Edition Pg No:61
•• Vaginitis – abnormal vaginal discharge with vulvar
burning, irritation or itching.
•• Leading causes- bacterial vaginosis, candidiasis and
trichomoniasis.

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 Section A  Recent Questions 2019

Summary of Characteristics of Common Vaginal Infections

Category Physiologic Bacterial vaginosis Candidiasis Trichomoniasis Bacterial
Complaint None Bad odour Itching, burning, Frothy discharge, Thi, watery
discharge bad odour, dysuria, discharge, pruritus
pruritus, spotting
O/E- subepithelial
hemorrhages in
vagina- strawberry
vagina
Discharge White, clear Thin, grey or white, White cottage Green yellow, frothy, Purulent
adherent cheese like adherent, increased
KOH whiff test Absent Present Absent May be present Absent
Vaginal pH 3.8-4.2 >4.5 <4.5 >4.5 >4.5
Microscopic findings NA Clue cells Budding yeast Trichomonads may Many WBCs
with mycelia or be seen moving
pseudohyphae

235. Which of the following is an absolute contraindication •• Diabetes with vascular complications
to OCP use: •• Migraine with focal neurologic symptoms
a. Chronic renal disease (B) Diseases of the Liver
b. DVT
•• Active liver disease
c. Diabetes mellitus
•• Liver adenoma, carcinoma
d. History of amenorrhea
(C) Others
Ans.  (b) DVT •• Pregnancy
Ref: Speroff Clinical Gynecologic Endocrinology and •• Breastfeeding (postpartum 6 weeks)
Infertility 8th Edition Pg No:1033; Shaw’s text book of •• Major surgery or prolonged immobilization
Gynaecology, 16th Edition Pg No:274 •• Estrogen dependent neoplasms, e.g. breast cancer
Combined oral contraceptive pills: Relative Contraindication:
•• Most effective mechanism: inhibition of ovulation •• WHO Category–2 : (Advantages outweigh the risks)
•• Pearl index: 0.1/100 women years ƒƒ Age ≥ 40 years
Some Benefits of Combination Estrogen plus Progestin ƒƒ Smoker < 35 years
Oral Contraceptives: ƒƒ History of jaundice
ƒƒ Mild hypertension
•• Increased bone density
ƒƒ Gallbladder disease
•• Reduced menstrual blood loss and anemia
ƒƒ Diabetes
•• Decreased risk of ectopic pregnancy
ƒƒ Sickle cell disease
•• Improved dysmenorrhea from endometriosis
ƒƒ Headache
•• Fewer premenstrual complaints
ƒƒ Cancer cervix or CIN
•• Decreased risk of endometrial (50%) and ovarian cancer
•• W HO Category–3 : (Risks outweigh the advantages)
(40%) (after 1 year of use)
ƒƒ Unexplained vaginal bleeding
•• Reduction in various benign breast diseases
ƒƒ Hyperlipidemia
•• Inhibition of hirsutism progression
ƒƒ Liver tumors (Benign)
•• Acne improvement
ƒƒ Breastfeeding (postpartum 6 weeks to 6 months)
•• Prevention of atherogenesis
ƒƒ Heavy smoker (> 20 cigarettes/day)
•• Decreased incidence and severity of acute salpingitis
ƒƒ Past breast cancer
•• Decreased activity of rheumatoid arthritis
Pills are Associated with:
Absolute Contraindication: •• Pituatory adenoma
(A) Circulatory Diseases (Past or present) •• Reduced carbohydrate tolerance
•• Migraine
•• Arterial or venous thrombosis
•• Thromboembolic disorders
•• Severe hypertension
•• Cervical dysplasia >> carcinoma of endocervix (after 5
•• History of stroke
years of use)
•• Heart disease: valvular, Ischemic
•• Monilial vaginitis.

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 Section A  Recent Questions 2019

236. Which of the following statement is correct about acute ENT

fatty liver of pregnancy?
a. Occurs in 1 in 1000 pregnancy 238. Inspiratory stridor is found in what kind of lesions:
b. Mostly seen in last trimester a. Supraglottic b. Subglottic
c. Common if female fetus is present c. Tracheal d. Bronchus
d. May be associated with decreased uric acid
Ans.  (a) Supraglottic
Ans.  (b) Mostly seen in last trimester
Ref : PL Dhingra 7th edition , chap 59 – congenital lesions of
Ref: Williams obstetrics 25th Edition Pg No:4/28 larynx and stridor , pg 333- 334
Acute Fatty Liver:
•• Most frequent cause of acute liver failure during
pregnancy
•• Occurs in 1 in 10000 pregnancy
•• Common with male fetus
•• Manifest late in pregnancy
•• MC complaint: nausea and vomiting
•• Serum bilirubin levels usually are <10 mg/dL
•• Serum transaminase levels are modestly elevated and
usually <1000 U/L.
•• Chances of IUD- very high
•• Recurrence is rare
•• Associated with increased uric acis and creatinine
237. Female with 41 wk gestation confirmed by radiological •• Airway obstruction above the glottis - an inspiratory
investigation, very sure of her LMP, no uterine stridor
contractions, no effacement and no dilatation. What •• Obstruction in the lower trachea & bronchi – indicative
should not be done? of expiratory stridor
a. Intracervical foley’s •• Lesion in glottic or subglottic lesion. - A biphasic stridor
b. PGE1 tab So answer is option a - supraglottis
c. PGE2 gel
d. PGF2alpha 239. Identify the lesion of vocal cord in the image given below:

Ans.  (d) PGF2alpha

Ref: DC Dutta obs 7th Edition Pg No:523
•• As in above question, patient is already 41 weeks so
need of termination of pregnancy which needs cervical
ripening and induction of labour.
•• Methods for cervical ripening:
Pharmacological Non-pharmacological
Prostaglandins (PGs) •• Stripping of membranes
•• Dinoprostone (PGE2): Gel, •• Amniotomy
tablet, suppository •• Mechanical dialators a. Reinke’s edema b. Laryngeal Papilloma
•• Misoprostol (PGE1): •• Transcervical balloon c. Malignancy d. Tracheomalacia
Tablets. catheter/ foleys catheter
•• Oxytocin •• Prostaglandins
•• Progesterone receptor •• Oxytocin Ans.  (b) Laryngeal Papilloma
antagonists •• Progesterone receptor Ref : PL Dhingra 7th edition , chap 61- benign tumours of
•• Mifepristone (RU 486) antagonists larynx , pg 344-345
ƒƒ Relaxin •• Relaxin
ƒƒ Hyaluronic acid •• Hyaluronic acid and •• Juvenile papillomatosis is the most common benign
ƒƒ Estrogen Estrogen neoplasm of the larynx in children.
•• It is viral in origin and is caused by human papilloma
DNA virus type 6 and 11

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 Section A  Recent Questions 2019

Clinical Features :: 241. A patient presented with the following picture of

•• Patient, often a child, between the age of 3 and 5 years Tympanic Membrane. Most Probable diagnosis (marked
- presents with hoarseness or aphonia with respiratory with arrow):
diffculty or even stridor.
•• Diagnosis is made by flexible fibreoptic laryngoscopy
Treatment consists of microlaryngoscopy and CO2 laser
excision avoiding injury to vocal ligament.
•• Recurrence is common and procedure needs to be
repeated several times
240. A child with H/o severe pain in throat with hoarseness of
voice , with high grade fever with toxic looks & presenting
with clinical condition as shown in the image. Identify
the lesion:

a. Tubercular Otitis Media

b. Syphilitic Otitis Media
c. Pseudomonas infection
d. Fungal Otitis Media

Ans.  (a) Tubercular Otitis Media

Ref: PL Dhingra 7th edition , chap 10 – disorders of middle
ear, pg 71
Features of Tuberculous Otits Media
•• Multiple perforations
a. Membranous tonsillitis •• Pale
b. Follicular tonsillitis •• Painless
c. Diphtheria •• Disproportionate hearing loss
d. Aphthous ulcer
The above picture shows multiple perforations – indicative
Ans.  (c) Diphtheria of tuberculous otitis media.
242. The most common site of the branchial cyst is:
Ref : PL Dhingra 7th edition , chap 51 , acute and chronic a. Posterior border of sternocleidomastoid
tonsillitis , page 294-295 b. Anterior border of sternocleidomastoid
•• Caused by the bacterium Corynebacterium diphtheriae. c. Digastric muscle
•• Signs and symptoms may vary from mild to severe. d. Omohyoid muscle
•• They usually start two to five days after exposure.
Sign & Symptoms Ans.  (b) Anterior border of sternocleidomastoid
•• Children are affected more often though no age group Ref : PL Dhingra 7th edition , chap 77 , neck masses , pg 446-447
is immune. Ans.  (b) Anterior border of sternocleidomastoid.
•• Oropharynx is commonly involved and the larynx and
Brachial Cyst:
nasal cavity may also be affected. In the oropharynx,
a greyish white membrane forms over the tonsils and •• It is common in the second decade of life but can occur
spreads to the soft palate and posterior pharyngeal wall. at any age with equal frequency in both sexes.
It is quite tenacious and causes bleeding when removed •• Cyst presents as a swelling in the upper part of the neck
•• Symptoms include high grade fever of 38 °C (100.4 °F) or anterior to sternocleidomastoid muscle.
above, chills, fatigue, bluish skin coloration (cyanosis), •• Mass is smooth, round, fluctuant, nontender and
sore throat, hoarseness, cough, headache, difficulty nontransilluminant.
swallowing, painful swallowing, difficulty breathing, •• Anomalies of the second branchial arch are the most
rapid breathing, foulsmelling and blood stained nasal common. A branchial cyst may be associated with a
discharge, and lymphadenopathy. sinus or a fistula

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 Section A  Recent Questions 2019

243. Name the maneuvre shown in the image: 244. Identify the condition of the given image:

a. Acquired cholesteatoma
b. Congenital cholesteatoma
c. Rupture of tympanic membrane
d. Keratosis obturans

Ans.  (d) Keratosis obturans

a. Brandt daroff b. Epley
c. Foster d. Semont Ref : PL Dhingra 7th edition , chap 8 , diseases of external
ear, pg 58
Ans.  (b) Epley •• Collection of a pearly white mass of desquamated
Ref : PL Dhingra 7 edition , chap 7 , disorders of vestibular
th epithelial cells in the deep meatus is called keratosis
system , pg 47-48 obturans.
•• The above image is a otoscopic picture / endoscopic
Epleys Repositioning Manuevere for BPPV picture showing a hard wax / white wax in the bony part
BPPV – benign paroxysmal positional vertigo of external auditory canal pointing towards KERATOSIS
•• In which there occurs movement of degenerated macula OBTURANS
into semicircular canal •• Pathology: Usually the epithelium from surface of
•• The principle of this manoeuvre is to reposition the tympanic membrane migrates onto the posterior meatal
otoconial debris from the posterior semicircular canal wall. If there is failure of this migration or any kind
back into the utricle of obstruction to migration caused by wax results in
•• The manoeuvre consists of fve positions (Figure 7.1): accumulation of the epithelial plug in the deep meatus.
ƒƒ Position 1. With the head turned 45°, the patient is made Clinical Features
to lie down in head-hanging position (Dix-Hallpike •• Usually patient presents with ear pain, hearing loss, ear
manoeuvre). It will cause vertigo and nystagmus. discharge or tinnitus.
Wait till vertigo and nystagmus subside.
ƒƒ Position 2. Head is now turned so that affected ear is Signs
facing up at a 90° rotation. •• On examination the ear canal is filled with a pearly white
ƒƒ Position 3. The whole body and head are now rotated mass of keratin material. Removal of this mass may
away from the affected ear to a lateral recumbent result in widening of bony meatus with ulceration and
position in a 90°-rotation face-down position. granuloma
ƒƒ Position 4. Patient is now brought to a sitting position Treatment
with head still turned to the unaffected side by 45°. •• Removal of keratotic mass by syringing or
ƒƒ Position 5. The head is now turned forward and chin instrumentation.
brought down 20° Treatment. Keratotic mass is removed either by syringing or
instrumentation

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 Section A  Recent Questions 2019

ORTHOPEDICS 246. Pott’s puffy tumor:

a. Subperiosteal abscess of frontal bone
245. Which part of scaphoid fracture is most susceptible to b. Subperiosteal abscess of ethmoid bone
avascular necrosis? (NEET PG Jan-2019) c. Mucocele of frontal bone
a. Distal 1/3rd d. Mucocele of ethmoid bone
b. Middle 1/3rd
Ans.  (a) Subperiosteal abscess of frontal bone
c. Proximal 1/3rd
d. Scaphoid Tubercle Ref: https://appliedradiology.com/articles/pott-s-puffy-
tumor
Ans.  (c) Proximal 1/3rd
•• Pott’s puffy tumor, first described by Sir Percivall
Ref: Turek’s orthopaedics,volume 2,page 1000,chapter Wrist Pott in 1760, is a rare clinical entity characterized by
•• Scaphoid fractures (i.e. fractures through the scaphoid subperiosteal abscess associated with osteomyelitis.
bone) are common, in some instances can be difficult •• It is characterized by an osteomyelitis of the frontal
to diagnose, and can result in significant functional bone, either direct or through haematogenous spread,
impairment. results in a swelling on the forehead.
•• The infection can also spread inwards, leading to an
Epidemiology
intracranial abscess.
•• Scaphoid fractures account for 70-80% of all carpal bone •• Pott’s puffy tumor can be associated with cortical vein
fractures. thrombosis, epidural abscess, subdural empyema, and
•• Although they occur essentially at any age, adolescents brain abscess.
and young adults are most commonly affected.
Investigations
Clinical Presentation
•• T/MRI With contrast
•• Classically there can be pain in anatomical snuffbox ••  Management includes abscess drainage, sequestrectomy
which is thought to have a sensitivity of ~90% and a of affected tissues and bone, as well as broad-spectrum
specificity ~40% postoperative intravenous antibiotic use for 6-8
•• Fractures can occur essentially anywhere along the weeks.3 Overall, the prognosis is generally good given an
scaphoid, but distribution is not even: accurate diagnosis and prompt treatment.
ƒƒ waist of scaphoid: 70-80%
247. Scissor gait is seen in which of the following condition:
ƒƒ proximal pole: 20%
a. Polio
ƒƒ distal pole (or so-called scaphoid tubercle): 10%
b. Cerebral palsy
Avascular necrosis: c. Hyperbilirubinemia
•• Fractures in the proximal 1/3 have a high incidence of d. Hyponatremia
AVN (~30%) ,bcz of less blood supply that too from distal
to proximal end . Ans.  (b) Cerebral palsy
•• Waist fractures in the middle 1/3 is the most frequent GAIT:
fracture site and has moderate risk of AVN.
•• It is defined as a translatory progression of the body as a
•• Fractures in the distal 1/3 are rarely complicated by AVN
whole produce by coordinated, rotatory movements of
body segments.

Phases of Gait:
Stance Phase:
•• Heel strike
•• Foot flat
•• Mid-stance
•• Heel off
•• Toe off
Swing Phase:
•• Acceleration
•• Mid-swing
•• Deceleration
Abnormal Gait:
•• Neurologic Gait:
ƒƒ Hemiplegic gait .
ƒƒ Ataxic gait
ƒƒ Scissoring Gait (crossed leg gait)
ƒƒ Parkinsons gait
•• Muscular Weakness Gait:
ƒƒ Gluteus medius Gait
ƒƒ Gluteus maximus gait 73
.
 Section A  Recent Questions 2019

•• Limb Length Discrepancy Gait:

•• Joint Muscular Limitation Gait:
Scissoring Gait: It results from spasticity of bilateral
adductor muscle of hip. One leg crosses directly over the
other with each step like crossing the blades of a scissor.
E.g. Cerebral Palsy
248. Which statement is incorrect about the pathology shown
in the image:

Ans.  (b) Spondylolisthesis

Spondylolisthesis:
Forward translation of one vertebra on another in the
a. Tumor arise from epiphyseal to metaphyseal region sagittal plane of the spine
b. Tumor has distinct margin Wiltse Classification
c. Eccentric lesion •• Type I: Dysplastic (child) ′
d. Chemotherapy is the treatment of choice •• Type II: Isthmic (5-50 yrs) ′
•• Type III: Degenerative (older) ′
Ans.  (d) Chemotherapy is the treatment of choice
•• Type IV: Traumatic ′
Ref: Textbook Of ORthopaedics ,Maheshwari & Mhaskar, •• Type V: Pathologic
6th Edition, page 238. C/F:
•• Backache ,Sciatica ,Pseudoclaudication d/t spinal
Given image is of Giant cell tumor
stenosis when subluxation is severe.
•• GCT, benign tumour with greater recurrence rate after •• Signs of nerve root compression- motor weakness, reflex
local removal , changes and sensory deficits.
•• LOCATION : Epiphysis
Radiographs
•• M/C Site: Lower femur,Upper Tibia,Lower radius
•• Age group: 20-40 yrs •• Ap/oblique views
•• INVESTIGATION: X RAY findings. •• Flexion /Extension Views
ƒƒ Soap bubble appearance •• Ferguson View
ƒƒ No calcification Meyerding Classification.
ƒƒ Thinned out cortex •• grade I: 0-25%
ƒƒ Eccentric location •• grade II: 26-50% 
The key histomorphologic feature is, as the name of the •• grade III: 51-75% 
entity suggests, (multinucleated) giant cells with up to a •• grade IV: 76-100%  
hundred nuclei that have prominent nucleoli. •• grade V (spondyloptosis): >100%
Treatment
•• Excision: Treatment of choice when tumour affects
bone whose removal does not hamper the functions .
•• Excision with reconstruction: when excision of tumour
may result in significant functional impairment ,defect
created by excision is augmented by reconstructive
procedure
•• Radiotherapy: Preferred treatment method for GCT
affecting vertebrae
249. What should be the most likely diagnosis of this 65
year old lady presents with backache and following
radiograph of the spine shown in image:
a. Osteoporosis b. Spondylolisthesis
c. Spondylolysis d. Discitis

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 Section A  Recent Questions 2019

Conservative •• Fracture of the femoral head.

•• Rest, anti-inflammatory agents , lumbar corset •• Sciatic nerve palsy.
•• Physical therapy, abdominal strengthening exercises, Complications:
hamstring stretching, •• Myositis ossificans ,sciatic nerve injury .
•• Avoidance of extension exercises which will exacerbate
the symptoms 251. Most common joint involved in septic arthritis:
a. Knee
Operative Treatment: b. Hip
c. Shoulder
Degenerative Spondylolisthesis: d. Elbow
•• Decompressive laminectomy ,
•• Decompression with posterolateral fusion ′ Ans.  (a) Knee
•• Decompression with instrumental fusion
Ref: Textbook of Orthopaedics,Maheshwari and Mhaskar,
Isthmic Spondylolisthesis : 6th edition,page177.
•• Grade 1,2,3 Meyerding- asymptomatic –observation
Septic arthritis (Acute suppurative arthritis)
•• Symptomatic – Activity modification
•• Grade 4,5 Meyerding: Surgery •• Septic arthritis refers to pyogenic infection of a joint, i.e.,
infection of a joint by pyogenic organism (bacteria).
250. Which of the following attitude will be seen in a patient
•• The joint can become infected by : –
with posterior dislo-cation of hip?
ƒƒ Hematogenous spread from a distant site (most
a. Flexion, Abduction, Internal rotation
common route).
b. Flexion, Adduction, Internal rotation
ƒƒ Direct invasion through a penetrating wound, intra
c. Flexion, Abduction, External rotation
articular injection, arthroscopy.
d. Flexion, Adduction, External rotation
ƒƒ Direct spread from adjacent osteomyelitis especially
Ans.  (b) Flexion, Adduction, Internal rotation in joints where Metaphysis is intra articular e.g., hip
and shoulder.
•• Posterior dislocations: Commonest and is seen in 80-90
percent of the cases Clinical Features
•• Anterior dislocations: Seen in 10-15 percent •• Disease is more common in children.
•• Central dislocations: Relatively rare •• Knee joint is the most commonly affected joint.
Posterior Dislocation: Hip is Flexed, Adducted, and •• Other joint which are affected are hip, shoulder and
Internally Rotated, and Leg Is Shortened. elbow. The child is toxic with fever, tachycardia,
tachypnea.
•• C/F:
•• There is severe pain, swelling, and redness over the joint.
•• Patient have marked shortening and gross restriction of
Movements are severely restricted and the joint is held
all hip movements. Head of the femur is felt as a hard
in the position of ease. Weight bearing on limb is not
mass in the gluteal region and it moves along with the
possible.
femur. Vascular sign of Narath is negative. features of
sciatic nerve palsy may be present. Treatment
Thompson and Epstein Classification: For Posterior Hip •• Early stage –before any signs of joint destruction, correct
Dislocation diagnosis and aggressive treatment can save a joint from
permanent damage
•• Type I: With or without minor fracture.
•• Whenever pus is aspirated. Joint should be opened up,
•• Type II: With a large single fracture of the posterior
washed and closed with suction drain
acetabular rim.
•• In late cases, radiological destruction of joint margins,
•• Type III: With communition of the rim of the acetabulum
subluxation or dislocation,It is not possible to expect
with or without a major fragment.
joint movement, in such cases Arthrotomy and extensive
•• Type IV: With fracture of the acetabular floor.
debridement of joint is done and joint immobilized in
•• Type V: With fracture of the femoral head.
position of optimum function.
Methods of Closed Reduction:
Complication:
•• Allis method
Deformity, Stiffness, Osteoarthritis
•• Bigelow method
•• Classical Watson Jones method 252. Painful arc syndrome pain is felt during ?
•• Stimson’s gravity method a. Mid abduction
•• Whistler’s technique(over-under) b. Initial abduction
Indications for Open Reduction: c. Full range of abduction
•• Failed closed reduction. d. Overhead abduction
•• Failed stability test. Ans.  (a) Mid abduction
•• Big posterior lip fragment.
•• Bone fragment within the acetabulum.

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 Section A  Recent Questions 2019

PAINFUL ARC SYNDROME Ans.  (a) Brodie abscess

Other Names Ref: Textbook of orthopaedics ,Maheshwari and Mhaskar,
•• Impingement syndrome 6th, edition, page 175
•• Supraspinatus syndrome •• Special type of osteomyelitis in which body defense
•• Swimmer’s syndrome mechanism have been able to contain the infection so as
•• Thrower’s shoulder to create a chronic bone abscess containing pus or jelly
Clinical syndrome characterized by pain in the shoulder like granulation tissue surrounded by zone of sclerosis
during an arc of movement between 60° and 120° of •• Age group : 11 to 20 yrs
abduction. •• M/C site : Upper end of Tibia and Lower end of Femur
Etiology: •• C/F: deep boring pain predominant symptom, pain
worse at night and made worse by walking , relieved by
•• Minor tears of the supraspinatus tendon
rest
•• Supraspinatus tendinitis
•• Calcification of supraspinatus tendon Location
•• Subacromial bursitis •• It has a predilection for ends (metaphysis) of tubular
•• Fracture of the greater tuberosity bones:
•• Increase in bulk of the contents in the subacromial Radiographic Features
space, seen in inflammation of the rotator cuff Plain radiograph
PAINFUL ARC TEST: Circular or ovalradiolucent area surrounded by zone of
sclerosis
This test is commonly used to identify possible subacromial
Management:
impingement syndrome. 
•• Surgical evacuation and curettage is performed under
Procedure:
Antibiotic cover
•• With the patient in either sitting or standing the patient
should be instructed to abduct the arm in the scapular 254. Foot drop is caused by injury to which nerve involvement:
plane. a. Femoral nerve
•• Following completion of the abduction movement b. Tibial nerve
(120”) the patient should then slowly reverse the motion, c. Common peroneal nerve
bring the arm back to neutral position via the movement d. Sciatic nerve
of adduction. Ans.  (c) Common Peroneal Nerve
•• This test is considered to be positive if the patient
experiences pain between 60 and 120 degrees of Foot Drop:
abduction which reduces once past 120 degrees of •• Inability to actively dorsiflex and evert the foot
abduction •• Types of foot drop
Treatment •• Type I – High above the level of fibular head deep
•• Non Operative -Antiinflammatory Medication, Subacro- peroneal nerve
•• Type II- Low below the level of fibular head superficial
mial Cortisone Injection,
peroneal nerve
•• Physiotherapy On Strengthning The Rotatory Cuff & Full
Range of Movements Low lesion /type 1 Low lesion/type 2 foot drop
•• Operative: Arthroscopic Or Anterior Acromioplasty
•• Total foot drop •• Incomplete foot drop
253. Identify the condition as shown: •• Unable to dorsiflex and •• Unable to do eversion
invert foot •• Able to do dorsiflexion and
•• Able to do eversion inversion of the foot
•• Wasting of ant group of •• Wasting of outer half of leg
muscles •• Sensation lost over outer leg
•• Loss of sensation over the and foot
1st web space

C/F:
Inability to lift the front part of the foot
•• Abnormal gait which drag the front of foot on the ground
during walking (steppage gait)
•• An exaggerated, swinging hip motion
•• Tingling, numbness & slight pain in the foot
a. Brodie abscess •• Difficulty performing certain activities that require the
b. Osteoid osteoma use of the front of the foot
c. Intracortical hemangioma •• Muscle atrophy in the leg Limp foot
d. Chondromyxoid fibroma

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 Section A  Recent Questions 2019

Gait of Foot Drop Gait is High Stepping Gait •• Clinically impetigo can be divided into the bullous and
non-bullous forms.
Electromyelogram •• Staph. aureus is the commonest organism incriminated
This study can confirm the type of neuropathy, establish in bullous impetigo. However, the non-bullous form can
the site of the lesion, estimate extent of injury, and provide be caused both by staphylococci and streptococci either
a prognosis alone or in combination.
•• Lesions in bullous (staphylococcal) impetigo are
Management:
relatively thick walled superficial bullae with very little, if
Physical Therapy: any, surrounding erythema. They persist for a couple of
•• Exercises that strengthen the leg muscles days and rupture, forming a very thin varnish-like yellow
•• Maintain the range of motion in knee and ankle crust
•• Improve gait problems associated with foot drop. •• Bulla is due to local action of epidermolytic toxin
(exfoliatin).
Nerve Stimulation:
•• The lesions of non bullous impetigo are erythematous
•• Stimulating the nerve (peroneal nerve) improves foot
macules over which thin roofed vesiculopustules
drop especially if it caused by a stroke.
appears. The roof of the vesiculopustule soon ruptures
Conservative Treatment: Shows High Incidence of and the seropurulent discharge dries up, forming a
Recovery loosely adherent, honey or straw-coloured or golden
•• Splintage – splint knee in 20° of flexion and ankle in 90° yellow, granular crust, which appears ‘stuck on
for night time 256. All are true about skin except
•• In day time, walking is allowed by using ‘footdrop a. Both dermis & ectoderm are derived from ectoderm
appliance’ b. Skin accounts for total of 15% of body weight
•• Varieties of foot drop appliances: i) dynamic-spring shoe c. Most of the cells in skin are keratinocytes derived from
ii) static- back stop shoe ectoderm
•• Ankle foot orthotics (AFO) -support the foot with light- d. Dermis is made up of type1 and type 3 collagen in 3:2
weight leg braces and shoe inserts ratio
•• Exercises -strengthen the muscle, help to maintain range
of motion (ROM) and improve gait Ans. (a) Both dermis & ectoderm are derived from
•• Electrical Functional Stimulations -electrically stimulate ectoderm.
the peroneal nerve
Ref: IADVL Textbook of Dermatology 4th edition Pg no: 7, 8,
Surgery – done if conservative management fails
26
•• With a surface area of 2m2 and accounting for 16% to 20%
DERMATOLOGY of the total body weight, the skin is the largest organ of
the body
255. The causative organism for the condition depicted in •• The epidermis is composed of stratified squamous
image is? epithelium, largely constituted by keratinocytes and a
few other cells like Melanocytes, Langerhans cells and
Merkel cells.
•• Skins embryonic development corresponds to the
embryonic period of zero to 60 days; it is the process
by which the ectoderm lateral to the neural plate is
committed to become the epidermis and the subsets of
mesenchymal and neural crest cells are committed to
form the dermis
•• Approximately 80% to 90% collagen fibers in the dermis
are type I; 8% to 10%, type II; and less than 5%, type V.
Type III collagen is small and intertwined with them.
257. A child with history of fever, photosensitivity, rash
sparing nasolabial fold presents to OPD. Identify the
condition?
a. Staphylococci b. Candida a. SLE
c. Streptococcus d. Actinomycetes b. Polymorphous light eruption
c. Discoid lupus
Ans.  (a) Staphylococci d. Skin tuberculosis
Ref: IADVL Textbook of Dermatology 4th edition Pg no: 226
Ans.  (a) SLE
Impetigo
Ref: IADVL Textbook of Dermatology 4th edition Pg no: 1225-
•• Impetigo is the most common skin infection in children. 28

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 Section A  Recent Questions 2019

•• SLE is commonly seen as the classic malar or butterfly •• Scabies like warm places, such as skin folds, between
rash, a fixed, well demarcated, symmetrical erythema the fingers, under fingernails, or around the buttock or
that can be flat or raised over the cheeks and bridge of breast creases.
the nose. •• Circle of Hebra:
•• It often involves the forehead, chin, ‘V’ area of the neck
and ears, but the nasolabial folds are characteristically
spared.
•• Nonorgan-threatening symptoms occur in most persons
during the course of active disease. These include
arthritis or arthralgia (84%), oral ulcers (24%), fever
(52%), and serositis (pleuritis or pericarditis; 36%).
258. Patient presents with pruritis of inter digital clefts of left
hand as shown in the image. Identify the condition?

•• It causes nocturnal itching at classical sites mentioned

above and similar history seen in close contacts.
•• Treatment of choice: 5% Permethrin cream
259. Identify the condition. This is child with asthmatic
mother.

a. Sarcoptes scabiei
b. Dermatitis herpetiformis
c. Xerotic dermatitis
d. Erythema multiforme

Ans.  (a) Sarcoptes scabiei

Ref: IADVL Textbook of Dermatology 4th edition Pg no: 422-
424
•• Scabies is an intensely pruritic skin condition caused by
infestation with the microscopic mite Sarcoptes scabiei.
a. Atopic dermatitis
•• Sarcoptes scabiei var hominis, and is transmitted from
b. SLE
person to person by skin-to-skin contact.
c. Erythema infectiosum
d. TEN

Ans.  (a) Atopic dermatitis

Ref: IADVL Textbook of Dermatology 4th edition Pg no: 529-
530
•• Atopic dermatitis (eczema) is a type of inflammation of
the skin (dermatitis) resulting in itchy, red, swollen, and
cracked skin. Also known as “atopic eczema”.
•• Long lasting (chronic) & tends to flare periodically.
•• Children with family history of atopy, asthma or hay
fever are more likely to develop atopic dermatitis.
•• The infantile phase, from birth to two years of age, is
characterized by erythematous papules and vesicles,
typically beginning on the cheeks and then in extensors.
•• Burrowed into the epidermis, the mite, its feces and ova •• The childhood phase is from two years to puberty.
laid by females cause the irritation leading to itching and Children exhibit more lichenified papules and plaques
secondary infection from scratching. with involvement are the hands, feet, wrists, ankles, and
popliteal and antecubital regions

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 Section A  Recent Questions 2019

•• The adult phase starts from puberty. Lichenified plaques a. Leukoderma b. Piebaldism
are seen in flexures, face and neck, the upper arms and c. Vitiligo d. DLE
back, and the dorsal aspects of the hands, feet, fingers,
and toes. Ans.  (a) Leukoderma
260. Identify the condition shown in the image? Ref: IADVL Textbook of Dermatology 4th edition Pg no: 594
•• Leukoderma is a skin disease that causes loss of skin
pigmentation (melanin) due to known cause leads to
skin whitening.
•• It is induced by certain chemicals that are destructive to
functional melanocytes, most commonly paratertiary
butyl phenol, para-tertiary butyl catechol, monobenzyl
ether of hydroquinone, hydroquinone and related
compounds.
•• These chemicals may be present in insecticides,
paints, plastics and rubber, lubricating and motor oils,
photographic chemicals, germicides and disinfectants,
detergents and deodorants, and inks.
•• They may depigment the skin on direct exposure,
sometimes followed by depigmentation of distant
a. Sebaceous cyst b. Alopecia areata untouched areas.
c. Trichotillomania d. Tinea capitis 262. Which of the following regarding the condition depicted
in the image?
Ans.  (b) Alopecia areata
Ref: IADVL Textbook of Dermatology 4th edition Pg no: 901-
903
•• Alopecia areata is an autoimmune disorder
characterized by transient, nonscarring hair loss and
preservation of the hair follicle. It can be associated with
other autoimmune conditions.
•• Hair loss can be well-defined patches to diffuse or
total hair loss, affecting scalp, eyebrow, eyelash beard,
moustache or body hair..
•• It presents as a smooth, well-defined, round or oval,
totally bald patch slightly depressed below the surface,
being deprived of the volume of hair bulbs
•• Exclamation mark hairs are seen as 2–4 mm long broken
hair, the shafts of which reduce progressively in thickness a. May be an indication of skin malignancy
and pigmentation toward the bulb end. b. Hypopigmentation
•• White hairs are relatively spared in Alopecia areata c. May be associated with Insulin resistant diabetes
•• A peribulbar lymphocytic infiltrate in a “swarm of bees” mellitus
pattern is the typical histopathological pattern d. Commonly occurs in lean and thin.
•• Topical and oral steroids, tacrolimus, contact sensitisers,
immunomodulators can be given. Ans. (c) May be associated with Insulin resistant
diabetes mellitus
261. Identify the condition in the image?
Ref: IADVL Textbook of Dermatology 4th edition Pg no: 1009-
1010
•• Acanthosis nigricans is associated with obesity, insulin
resistance and PCOD in majority of the patients. Most
common association is obesity.
•• Acanthosis nigricans (AN) is a skin disorder characterized
by hyperpigmentation and hyperkeratosis of the skin.
•• Occurs primarily in flexural areas as velvety
hyperpigmentation in neck, axilla and groin.
•• Other associations are acromegaly, cushing’s syndrome,
hyperandrogenism & GIT malignancy.
•• Acanthosis nigricans has been classified into the
following types: hereditary, benign, pseudoacanthosis
nigricans, drug-induced, malignant and nevoid.

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 Section A  Recent Questions 2019

OPHTHALMOLOGY •• In young hypermetropic individuals where ample

reserve of accommodation is present, the patient uses
263. Identify the instrument: his accommodation to see near and distant objects.
Along with accommodation, convergence occurs-
ESOTROPIA.
ƒƒ Excess accommodation also leads to pseudomyopia
and accommodative asthenopia.
ƒƒ In hypermetropia, pseudoexotropia is seen (Apparent
divergent squint )
ŠŠ Inn myopia, since patient will be having good near
vision, convergence is not much used. So eye tends
to diverge  DIVERGENT SQUINT .
ŠŠ PSEUDOESOTROPIA/ APPARENT CONVERGENT
SQUINT is seen in myopia .
a. Maddox rod b. Maddox wing 265. In the given condition, cause of defective vision is
c. Maddox glass d. Red glass

Ans.  (a) Maddox rod

Ref: A K Khurana Comprehensive Ophthalmology , 7th
edition , pg no. 203, 360

MADDOX ROD:
•• Made of series of high plus plano cylindrical lens.
•• Due to the optical properties, the point light is converted
into a line and the streak of light is seen perpendicular to
the axis of the cylinder.

a. Visual axis is obscured

b. Astigmatism
c. Hypermetropia
d. Diplopia

Ans.  (a) Visual axis obscuration

Ref : Parson’s Diseases of the eye , 22nd edition, page no. 184 .

Pterygium:
Definition:
A degenerative condition of the subconjunctival tissue
Uses which proliferates as vascularised granulation tissue to
•• Squint evaluation – to detect heterophoria invade the cornea .
•• Macular function test – to assess the macula in case of Pathogenesis:
dense cataract •• Elastotic degenerationof the subconjunctival tissue with
264. Esotropia is commonly seen in which type of refractive fibrovascular proliferation .
error ? •• Destruction of epithelium & Bowman’s layer by
a. Myopia b. Hypermetropia advancing fibrovascular tissue resulting in corneal
c. Astigmatism d. Presbyopia scarring.
Cause Of Defective Vision In Pterygium :
Ans.  (a) Hypermetropia •• Fibrovascular tissue contracts  flattening of the cornea
Ref : Parson’s Diseases of the eye , 22nd edition, page no. 246. in the horizontal axis  ASTIGMATISM {WITH THE
RULE ASTIGMATISM }
Hypermetropia: •• Obscuring the pupillary region or the Visual axis .
•• It is the refractive error in which the incident parallel Types Of Pterygium: Depending upon the growth
rays of light are brought to a focus posterior to the light
sensitive layer of the retina when the accommodation is
at rest.

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 Section A  Recent Questions 2019

267. A 25 year old young patient met with a road traffic

PROGRESSIVE PTERYGIUM STATIONARY/ATROPHIC
accident complaints of diplopia.on examination, pic .
•• Thick & Fleshy PTERYGIUM
CT scan shows (pic)
•• Highly vascularised •• Thin & pale
•• Cap present •• No vascularisation
•• No cap

•• STOCKER’S LINE : seen in atrophic pterygium . Iron

deposition in front of the head in the corneal epithelium.
266. This test is used in

What is your diagnosis ?

a. Orbital blow out fracture
b. Orbital roof fracture
c. Oculomotor nerve paralysis
d. Retrobulbar hemorrhage

Ans.  (b) Orbital roof fracture

Ref : Parson’s Diseases of the eye , 22nd edition, page no. 499
a. Squint b. Heterophoria
c. Esotropia d. All the above •• The clinical picture shows restricted upward movement
of the left eye and CT orbit shows hanging drop sign.
Ans.  (d) All the above Orbital Blow Out Fracture
Ref : Parson’s Diseases of the eye , 22nd edition, page no. 184; •• Caused by sudden increase in the orbital pressure by an
A K Khurana Comprehensive Ophthalmology, 7th edition, impacting object which is greater in diameter than the
pg no. 365 orbital aperture (about 5 cm) like Fist or tennis ball
•• Lateral wall and the roof withstand trauma but Orbital
•• The test shown in picture is cover test / cover – uncover
floor & medial wall is weaker and give away leading to
test
blow out fracture
Cover Test Cover - Uncover Test Types:
Cover one eye  look for Cover either eye and uncover •• ‘PURE’ blow-out fracture only floor fracture not
movement in the other eye it  look for the movement in involving the orbital rim .
the same eye  fusion is lost •• ‘IMPURE’ fracture Involves the rim and/or adjacent
(Fusion is interrupted by this facial bones along with floor fracture.
test . so latent squint becomes Posteromedial part of the floor is the weakest part of the
manifest squint) orbital floor
Uses: Uses:
•• Confirms the presence of •• To diagnose latent squint Clinical Features
manifest squint . •• Periorbital edema / ecchymosis
•• To determine the type •• Emphysema with subcutaneous crepitus ( medial wall #)
of squint. (convergent / •• Paresthesia or anaesthesia in the distribution of Infra
divergent ) orbital nerve – LOWER LID , cheek, side of the nose ,
upper lip , upper teeth.

81
 Section A  Recent Questions 2019

•• Proptosis due to edema or hemorrhage imbibing water from the vitreous .

•• Enophthalmos  due to herniation of orbital contents Indications:
into the maxillary sinus
•• Acute rise in IOP  Primary angle closure glaucoma,
•• Diplopia due to entrapment of inferior oblique /
Secondary angle closure glaucoma , Posner Schlossman
inferior rectus / soft tissues in the area of the blow out
syndrome
fracture
•• In the pre-operative period to reduce IOP in case of lens
•• Associated ocular damage
induced glaucomas, trabeculectomy, etc.
268. Which one is Against the Rule astigmatism ?
Dosage:
a. + 2. 00 x 90* b. – 2.00 x 90*
c. + 1.50 x 180 * d. – 1.50 x 180 * •• 1-2 mg /kg body weight ; 20% solution
Adverse Effects:
Ans.  (a) + 2.00 x90*
•• Volume overload in cardiac patients
Ref: Parson’s Diseases of the eye , 22nd edition, page no. •• Increase in BP
53,76 Other Hyperosmotic Agents:
CLUE is + power at 90* / - power at 180* is WITH THE •• Glycerol – increases blood glucose . Contraindicated in
RULE ASTIGMATISM. Diabetics .
Astigmatism : •• Urea – not routinely used
•• Isosorbide
Definition : When the rays are focused at different points
due to unequal refraction in different meridians . 270. The ocular hypotensive agent causing apnoea in infants
is
With the Rule Astigmatism: a. Latanoprost b. Timolol
•• Vertical meridian is more curved than the horizontal c. Betaxolol d. Brimonidine
meridian
•• Eg : Normal eyes (0.25 D), pteyrgium Ans.  (d) Brimonidine
•• 90* axis >>>> 180* axis (+ lens at 90* /- lens at 180*)
Ref: A K Khurana Comprehensive Ophthalmology, 7th
Refraction through cylindrical / toric surface is called edition , pg no. 469
STRUM OF CONOID
Brimonidine:
Against the Rule Astigmatism •• Selective alpha 2 agonist
•• When the horizontal meridian is more curved than the •• MOA: decreases aqeous production & increases the
vertical meridian uveoscleral outflow
•• 180*>>>>90* axis (- lens at 90* /+ lens at 180*) •• Neuroprotective Effect
•• Eg: Post op astigmatism –suture related Adverse Effects:
Oblique Astigmatism
Ocular Systemic
•• The two principal meridias are at right angles to each
other ; but not the vertical and horizontal meridian like Allergic conjunctivitis •• Cross the blood–brain barrier
45* and 135 * Granulomatous anterior → severe central nervous
uveitis- rare system (CNS) depression,
Bioblique Astigmatism
apnoea and hypotension can
•• The two principal meridias are not at right angles and occur (contraindicated under
also not the vertical and horizontal meridia . eg : 30* & the age of 2 years)
100* •• Xerostomia and fatigue
269. Intravenous Mannitol is indicated in
a. Primary Open angle glaucoma 271. The dosage of Vitamin A in keratomalacia ina 2 year old
b. Acute angle closure attack boy who is 12 kg weight is
c. Normal tension glaucoma a. Vitamin A :2 lakh I U, oral, 1st, 2nd and 14th day
d. Sympathetic ophthalmitis b. Vitamin A :1 lakh I U, oral, 1st, 2nd and 14th day
c. Vitamin A :2 lakh I U, oral , 1st, 2nd and 3rd day
Ans.  (b) Acute angle closure glaucoma d. Vitamin A :1 lakh I U, oral, 1st, 2nd and 3rd day
Ref : Parson’s Diseases of the eye , 22nd edition, page no.
Ans.  (a) Vitamin A :2 lakh I U ,oral , 1st , 2nd and 14th
53,76; A K Khurana Comprehensive Ophthalmology , 7th
day
edition , pg no. 472
•• Iv mannitol is an hyperosmotic agents which acts by Ref : Parson’s Diseases of the eye, 22nd edition, page no. 218;
increasing the osmotic pressure in the plasma thereby A K Khurana Comprehensive Ophthalmology, 7th edition,
pg no. 488

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 Section A  Recent Questions 2019

Xerophthalmia : 273. The most common cause of proptosis in adults is

•• Spectrum of ocular disease ranging from night blindness a. Orbital cellulitis
to corneal melting caused by vitamin A deficiency. b. Preseptal cellulitis
c. Thyroid eye disease
Who Classification of Xerophthalmia: d. Capillary hemangioma

Classification Ocular signs Ans.  (c) Thyroid eye disease

XN Night blindness Ref: A K Khurana Comprehensive Ophthalmology, 7th
X1A Conjunctival xerosis edition , pg no. 398

X1B Bitot’s spots Children Adult

X2 Corneal xerosis Unilateral – ORBITAL Unilateral – thyroid
X3A Corneal ulceration-keratomalacia involving CELLULITIS ophthalmopathy
one-third or less of the cornea Bilateral – neuroblastoma & Bilateral – thyroid
leukemia ophthalmopathy
X3B Corneal ulceration-keratomalacia involving
one-half or more of the cornea 274. Which one of the procedure involves using glaucoma
XS Corneal scar drainage device?
a. Seton operation b. Deep sclerectomy
XF Xerophthalmic fundus c. Viscocanalostomy d. Trabeculectomy
Treatment:
Ans.  (a) Seton operation
•• MEDICAL EMERGENCY especially in malnourished
infants. Ref: A K Khurana Comprehensive Ophthalmology , 7th
edition , pg no. 263
Vitamin A Dosage:
•• 2 LAKH I.U - ORALLY OR 1 LAKH I.U – I.M Glaucoma Drainage Devices
•• 3 doses are given = DAY 1, DAY 2 & WITHIN 1-4 WEEKS •• Plastic devices which allow aqeous outflow by creating
ƒƒ Children between 6-11 months: half the dose an alternative communication between the anterior
ƒƒ Children < 6 months : quarter the dose chamber & the Sub Tenon’s space .
272. Which of the parameter is decreased in Retinitis •• SETON OPERATION: surgery using glaucoma valve
pigmentosa ? •• Implants: Molteno implants , Krupin Denver and
a. Arachidonic acid b. Docosahexanoic acid Ahmed valve
c. Thromboxane d. Trielonic acid Indications:
•• Neovacular glaucoma
Ans.  (b) Docosahexanoic acid
•• Glaucoma with aniridia
Ref: https://iovs.arvojournals.org/data/journals/ •• Intractable glaucomas where trabeculectomy with anti-
iovs/933393/2596.pdf by J Gong - 1992 ; metabolite therapy fails
•• Retinitis Pigmentosa is a familial disease characterized 275. A 3 year old child is presenting with drooping of upper
by degeneration of photoreceptor with progressive night lid since birth. On examination , the palpebral aperture
blindness and constriction of peripheral vision (may height is 6 mm and with poor levator palpebrae superioris
lead to functional blindness) function. What is the procedure recommended?
•• Docosahexanoic acid (DHA) comprises a small a. Observation
percentage (1–4%) of the total fatty acids of the b. Fasanella Servat operation
membranes of most human tissues; however, it accounts c. Frontalis Sling surgery
for 30–40% of fatty acids in rod photoreceptor outer d. Mullerectomy
segments of the human retina.
•• Many patients with RP have lower plasma and red blood Ans.  (c) Frontalis Sling surgery
cell (RBC) lipid levels of the polyunsaturated fatty acid Ref : A K Khurana Comprehensive Ophthalmology , 7th
docosahexaenoic acid than non-affected individuals . edition , pg no. 395
The majority of patients with XLRP had 30–40% lower
DHA levels in RBC lipids than normally sighted controls Ptosis:
RP TRIAD: •• Ptosis or blepharoptosis ( Greek – to fall ) is the drooping
•• Includes fundus findings: Waxy pallor of the disc, of the upper eyelid to a level that covers more than 2mm
arteriolar attenuation and bony corpuscular pigment of the superior cornea.
clumps at the mid – peripheral retina .

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 Section A  Recent Questions 2019

Classification : 278. Which of the following is not cardio-depressive?

a. Propofol b. Thiopentone
Congenital c. Ketamine d. Etomidate
•• Simple
•• Associated with Superior Rectus weakness Ans.  (d) Etomidate
•• Associated with Marcus Gun Jaw Winking phenomenon
Ref: Stoelting’s Pharmacology and Physiology in Anesthetic
Acquired Practice 5th edition Page No. 169 & 170
•• Neurogenic – III Cn palsy , Horner’s syndrome •• Induction with etomidate at a dose of 0.3mg/kg is
•• Myogenic - myasthenia gravis, ocular myopathy, senile characterised by cardiovascular stability which is the
•• Mechanical – excess weight due to edema, tumors major advantage with the use of this drug.
•• Traumatic – trauma to levator palpebrae •• Its actions on the cardiovascular systems include –
Management minimal changes in HR, SV, CO (heart rate, stroke
volume, cardiac output).
TREAT the systemic cause •• The depressive effects of etomidate are minimal at
Mild Ptosis: concentrations required to produce anaesthesia when
•• Mullerectomy Muller muscle resection for 1mm ptosis compared to the other IV anaesthetics.
( HORNER’S SYNDROME) 279. Which of the following is the most common method used
•• Fasanella Servat operationsimple tarsoconjunctival to know depth of anaesthesia?
resection a. BIS
Modearte Ptosis b. Oesophageal contractility
•• With fair - good levator functionLEVATOR RESECTION c. Depressed Responses
d. Hypotension
Severe Ptosis with Poor Lps Function
•• BROW SUSPENSION / FRONTALIS SLING SURGERY Ans.  (a) BIS – Bispectral Index
where Lids are attached to the frontalis muscle with a Ref: Understanding Anesthetic Equipment and Procedures –
silicon tube. So with the contraction of frontalis , lids Baheti & Laheri Page No. 304 & 305
elevate.
•• BIS monitoring was first introduced for clinical use
in 1996. It was approved by FDA as a technique of
ANAESTEHSIA monitoring depth of anaesthesia and reducing the
incidence of intraoperative awareness during General
276. Anaesthetic gas with maximum respiratory irritation anaesthesia in 2004.
a. Halothane b. Enflurane •• 100 – Awake
c. Desflurane d. Sevoflurane •• 80 – light / moderate sedation
•• 60 – General anaesthesia
Ans.  (c) Desflurane •• 40 – Deep hypnotic state
•• 20 – burst suppression
Ref: Stoelting’s Pharmacology and Physiology in Anesthetic •• 0 – isoelectric EEG
Practice 5th edition Page No. 101
•• Desflurane, unlike halothane or sevoflurane has
a pungent smell which makes it unpleasant for RADIOLOGY
inhalational induction.
•• When more than 6% desflurane is used, the pungency 280. Which of the following is water soluble contrast?
produces salivation, airway irritation, breath holding a. Barium b. Iodine
and coughing. c. Bromium d. Calcium
277. IV administration of which drug is most painful among
the following? Ans.  (b) Iodine
a. Methohexitol b. Ketamine Ref: Grainger & Allison’s diagnostic radiology a textbook of
c. Propofol d. Etomidate medical imaging, 6th edition
•• Iodine-Based Contrast Media: Iodine (atomic number
Ans.  (c) Propofol
53 and atomic weight of 127) is the only element that is
Ref: Stoelting’s Pharmacology and Physiology in Anesthetic proved satisfactory for general use as an intravascular
Practice 5th edition Page No. 168 & 170 contrast medium for radiography including angiography
•• Pain on injection is the most commonly reported and CT.
adverse event during propofol administration. Not seen •• The iodine provides the radiopacity; the other elements
with etomidate due to use of etomidate in lipid emulsion of the contrast medium molecule provide no radiopacity
vehicle. but act as carriers of the iodine, greatly increasing the

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 Section A  Recent Questions 2019

solubility and markedly reducing the toxicity of the

molecule. The problem has always been how to pack the
iodine so it may be delivered safely into very sensitive
arterial systems (e.g. brain, heart, kidneys) in the very
large amounts required toproduce adequate radiopacity.
•• All four are tri-iodo benzene ring derivatives with three
atoms of iodine at 2,4,6 positions in monomers and six
atoms of iodine per molecule of the ring atom in dimers;
they are very hydrophilic; have low lipid solubility, low
toxicity, low binding affinities for protein, receptorsor
membranes; and have molecular weights less than 2000.
281. Identify the infection from the chest X-ray of patient with
low grade fever?
•• CT image -Blow out fracture of left orbit
•• Blunt trauma to the front of the orbit causing a blow-
out leads to enophthalmos and possibly diplopia due
to muscle entrapment, e.g. inferior rectus. The inward
displacement of the eyeball temporarily increases orbital
pressure, resulting in outward fracture of the thin bone
of the orbital floor or medial wall (lamina papyracea
of the ethmoid), but leaving the orbital rim intact. The
orbital soft tissues herniate through the defect into the
maxillary sinus.
283. Identify the condition in the below image?

a. ILD
b. Bronchopneumonia
c. Miliary TB
d. Consolidation

Ans.  (b) Miliary TB

Ref: Radiology Review Manual Seventh Edition Wolfgang
Dahnert, M.D.
•• Grainger & Allison’s diagnostic radiology a textbook of
medical imaging, 6th edition
•• Classically a manifestation of primary disease, miliary
tuberculosis is now more commonly seen as a post- a. Lacunar infarct b. Embolic infarct
primary process in older patients. Multiple small c. Thrombotic infarct d. Intracerebral hemorrhage
(1–2 mm) discrete nodules are scattered evenly
throughoutboth lungs in chest radiograph. Ans.  (a) Lacunar infarct
•• D/D diffuse metastatic disease, Fungal , noninfectious
Ref: Radiology Review Manual Seventh Edition Wolfgang
granulomatous disease (pneumoconioses, sarcoidosis,
Dahnert, M.D. Grainger & Allison’s diagnostic radiology a
eosinophilic granuloma)
textbook of medical imaging 6th edition
282. A patient presented with history of diplopia and
restricted eye movements. A clinical image and CT Lacunar Infarct Brain:
image is shown below. What will be the diagnosis? •• Lacunar infarcts are small (<15 mm) infarcts in the distal
a. Le- fort fracture b. Fracture maxilla distribution of deep penetrating vessels (lenticulostriate,
c. Fracture zygomatic d. Blow out fracture thalamoperforating, and pontine perforating arteries,
recurrent artery of Heubner). They result from occlusion
Ans.  (d) Blow out fracture of one of the small penetrating end arteries at the base of
Ref: Grainger & Allison’s diagnostic radiology a textbook of the brain and are due to fibrinoid degeneration.
medical imaging 6th edition •• In CT acutely, lacunar infarcts are often rounded with a
hazy outline and may fluctuate in size in the subacute
phase—most often enlarging.

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 Section A  Recent Questions 2019

PSYCHIATRY Ref: Knopp J, Knowles S, Bee P, Lovell K, Bower P. A

systematic review of predictors and moderators of response
284. Not true about somnambulism among the following is? to psychological therapies in OCD: Do we have enough
a. Sleep walking. empirical evidence to target treatment?. Clinical Psychology
b. Patient consciousness is preserved Review. 2013;33(8):1067-1081.
c. Disorder of sleep arousal •• Poor response to psychological therapies in OCD
d. Low level motor skill/function is present. •• Hoarding pathology
•• Increased anxiety and OCD symptom severity
Ans. (b) Patient consciousness is preserved; (d) Low •• OCD symptom subtypes such religious, sexual,
level motor skill/function is present. contamination
Ref: Kaplan & Sadock’s Synopsis of Psychiatry 10th edition •• Unemployment
Pg. no 762 •• Being single/not married. 
•• Somnambulism  is an arousal parasomnia consisting 287. Test based on the principle of suspect’s reaction, if he
of a series of complex behaviours that result in large witnesses an event then he behaves in a certain way is?
movements in bed or walking during sleep. a. Narcoanalysis b. Brain mapping
•• Also called sleep walking, in this condition individual c. Truth serum testing d. Polygraph
arises from bed and ambulates without fully awakening.
Ans.  (d) Polygraph
•• Individuals can engage in a variety of complex
behaviours while unconscious. Ref: Narco-Analysis, Polygraph And Brain-Mapping: A
•• Sleepwalks characteristically begin toward the end of Glimpse
the first or second slow wave sleep episodes (NREM •• Narcoanalysis is a test carried out on a patient or suspect
stage III and IV). when he/she, after administering truth serum, comes in
•• Sleepwalking episodes may range from sitting up and a sleep like state, and his/her repressed feelings are
attempting to walk to conducting an involved sequence released.
of semi-purposeful actions •• Truth serum are drugs used in narcoanalysis. Two
285. Confusion assessment scale used for which of the most common drugs used in narcoanalysis are
following? Sodium amytal, which is also known as amobarbital
a. Schizophrenia b. Delirium or amylobarbition, and Sodium Pentothal commonly
c. Dementia d. Depression known as thiopental or thiopentone
•• Polygraph measures and records physiological
Ans.  (b) Delirium actions of human body especially autonomic nervous
Ref: Grover S. Assessment scales for delirium: A review. system while the subject is asked questions relating to
World Journal of Psychiatry. 2012;2(4):58. the crime and he answers them.
•• It is based on the principle that autonomic nervous
Scales Used in Delirium system changes are beyond reasonable control of
an individual and hence autonomic nervous system
Screening of Delirium response changes transpires when the subject tries to
•• NEECHAM confusion scale tell a lie.
•• Delirium observation scale  •• Brain mapping measures the P300 evoked potential.
•• Diagnosis of Delirium In this test the suspect is made to sit in evoked potential
•• Confusion assessment method (CAM), recording machine and is shown objects relating to
•• CAM for intensive care unit (CAM-ICU), crime scene or is made to hear sounds pertaining to
•• Delirium Rating Scale-revised version (DRS-R-98), crime site. The sensors from his head pick the event
•• Memorial selirium assessment scale for diagnosis related potentials in the form of Brain Mapping only if
•• Delirium in Paediatric Age Group the person has been at the site of crime. The accuracy of
•• Paediatric Anaesthesia Emergence Delirium scale Brain Mapping is almost 100%.
•• Paediatric CAM-ICU  288. Intense depression & misery without any cause is?
286. Which of the following type of OCD has the poor response a. Melancholia b. Major depressive disorder
Exposure and Response prevention? c. Mania d. Schizophrenia
a. Magical thinking
b. Dirt contamination Ans.  (a) Melancholia
c. Pathological doubt
Ref: Kaplan & Sadock’s Synopsis of Psychiatry 10th edition
d. Hoarding
Pg. no 1892
Ans.  (d) Hoarding •• Melancholia is severe depressive state with psychomotor
retardation

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 Section A  Recent Questions 2019

289. Which of the following is not true regarding delusional

disorder?
a. Early immigration
b. Social isolation
c. Sensory impairment
d. Occurs at early age

Ans.  (d) Occurs at early age

Ref: Kaplan & Sadock’s Synopsis of Psychiatry 10th edition
Pg. no 432
Risk factors :
•• Advances age
•• Sensory loss
•• Recent immigration
•• Social isolation
•• Family history
•• Personality traits

87