Q 104. Q105. Q106. Q.107 Q108. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2007 © 1205 Answer is C (Low Prevalence) : Read text below There will be more false positive cases in a community where prevalence is low, Because the predictive accuracy of the testis decreased. Remember : Total positive =True Positive + False Positive Predictive value of a positive test indicates the probabilty that a patient witha positive test result, has infact the disease in question. That i it indicates the number of True Positives. Thus, ‘+ when the Predictive value of a positive testis high the no. of True Positive is high and the False Positive is low, + when the Predictive value ofa testis low the no. of True positives is low and this means that False positive will be high. This predictive value however th 1 of a disease, (besides its sensitivity & specifity) ‘The more prevalent a disease in a given population, the more is the predictive value ofa given test. Thus, The more prevalent a disease, the more will be the True positive and the less will be the false positives. The less prevalent a disease ,the less will be the True positives and the more will be the false positives. Thus there will be more false positive cases in a community where prevalence is less because, the predictive accuracy of the test is decreased. Low prevalence is the best answer Answer is D (Y community has low prevalence) :Read text below Predictive value depends on : sensitivity, specifity and prevalence of a disease. Because the same test is applied to both the communities, the sensitivity & specifity which are 'test dependent" will remain the same. Thus here the only reason for different positive rates can be a difference in the prevalence of the disease in these communities. > ‘As explained above, the no. of false +ve will be more, when the prevalence is less because, the predictive value of a test and hence its ability to identify the true poditive is decreased. Therefore Y shows more false +ves because the prevalence of disease in question in Y community is low. Answer is (Increased specificity and pasitive predictive value) : ELISA is an extremely good screening test with a high sensitvity of over 99.5% but low specificity. Harrison 14th/I1, 1815. The specificity of the technique is increased by carrying out ELISA tests in a row using different HIV marker. API 6135 Predictive value depends on sensitivity, specificity and the positive predictive value, ‘Thus double ELISA increases the specificity and the positive predictive value, The Answer is A (Paired t-test): Q.135/ AI 2000 Paired T-test: is applied to paired data when each individual gives a pair of observation, such as when observations are made both before and after the play ofa factor. eg. Pulse rate before and after administration of a drug. In the question above serum lipid levels were tested both befoe and after administering a hypolipidemic drug. A paired test therefore is most suitable in this case. For details see Q 135 / AI-2000. ‘The Answer is A (Alpha error) : Lawrence D. Budnick’s statistics; NMS (Public Health) /54 Type I Error : Alpha level Itisa sampling error Ifa study finds a difference in treatment when there is no difference actually, then a type I error is present. Under these circumstances results are falsely positive (false +ve) Thisis an error at alpha level. Type II Error : Beta level It determines the power of a study Ifa study fails to find a difference in treatment when actually there isa difference a type Il error is said to have occurred Under these circumstances results are False negative Thisisan error at f level.11206 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 Q109. Quo. qui. Quiz MEDICINE Qu3. Quis. ratio) : Park 23rd/58 ‘Total no of deaths due to aparticular disease x 100 ‘Total no. of cases due to some disease + Case fatality Rate is actually a Ratio + ItRepresents the killing power ofa disase usefullness in chronic diseases is limited) Answer is A (Amemia) : Park 23ni/808, 809 Hazards in dye industry include: 1. Bronchial Asthma 2. Skin, bladder and kidney diseases (CA Bladder) - $61 Park 3. Precancerous lesion Anemia is not a hazard in the dye industry and thus its screening is not mandatory. Answer is B (Serum ferritin) : Park 23rd/623 "The single most sensitive tool for evaluating the iron status is by measurement of serum ferritin"-Park "It is the most usefull indicator of iron status in 2 populateion where the population” of iron deficiency is not high. The Answer is B (Absolute Alcohol) : Diagnostic Microbiology 2nd/29; Clinical Microbiology 7th/145 ‘Sterilization refers to removal of all forms of life, including bacterial spores. This may be accomplished by Physical and Chemical methods. ‘Thus a complete sterilizing agent needs to act on spores also, Out ofthe choices provided: Glutaraldehyde, Hydrogen Peroxide, & Sodium Hypochorite, all may act on. spores as well. Although Alcohols have a wider spectrum, they are not sporicidal - Hence they cannot be referred to as, Complete Sterilizing agents. Answer is D : (Normal A-a gradient) API 6th/277; Harrison 17/1590, 15th/1452; 16%/1583-84 Respiratory failure is defined as a disorder wherein, lung function is inadequate to meet the metabolic demands of the individual and is unable to maintain normal arterial gas levels in the blood. Iti of two types : PaO, = decreased (<60 mm Hay Normal orlow (< 49 mm Hg) PaCO, Increased (> 49mm Hg) IP,.0. creased P,.0, _:normal is type 1s caused by conditions which affect This pe Is cause by conditions causing joxygenation, like hypoventilation as in J+ parenchymal diseases (V-Q mismatch) Obstructive lung disease: COPD, F. body Jediseases of vasculature/shunts + Decreased central respiratory drive Jr interstitial lung diseases. eg. CNS disorders ike : Brain injury (Examples: Meningitis, |- Pneumonia’ |; ARDS? ‘+ Weakness of respiratory muscle e.g. |- Emphysema’ peripheral N.S. disroderslike: M. gravis. |-Right to left shunts @ - Intestitial lung disease. - MS disorders like polymyositis. = Rib cage disorders : Kyphoscoliosis. ‘Answer is B (non small cell earcinoma) : Harrison 174/ 552-554, 16%/508 ‘Clubbing and non productive cough in presence of an apical lobe lesion(periperal) is suggestive of non small cell variant of Ca lung. CA Lung : following features associated with Carcinoma lung will help you understand the above + Most common symptom seen with carcinoma lung: persistent cough -cough is non productive initially, followed later by productive nature + Most common histological variety associated with clubbing is : non small cell carcinoma.Quis. Quis. [AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 1207 + Most common histological variety that presents af peripheral location is : adenocarcinoma -adenocarcinoma isa non small cell carcinoma The above three points clearly indicate the diagnosis of the carcinoma lung of a non small cell variety in this patient. ‘Tuberculosis although, may present with such symptomatology, the age of the patient and non productive nature of cough go against its diagnosis. Other questions on this topic ‘Most frequent histological type "Adenocarcinoma ® Most frequent histological type in India Squammous cell carcinoma Most common histological variety in life timenon-smokers | : Adnocarcinoma ®Most common histological vareity in young patients Adenocarcinoma ‘Most common histological variety in females Adenocarcinoma ®Most common site for metastasis from Ca lung : liver (page s21/H) ‘Most common endocrine organ to be involved by metastasis from Ca lung Adrenals. Ca lung which metastizes to opposite lung Adenocarcinoma. Commonest tumor to metastise to heart :Calung (Bronchogenic Ca) ‘Histological varieties that cavitate : squamous cell and large cell. Histological varieties that are central in distribution juamous cell and small cell ‘¢Histological varieties that are peripheral in distribution : Adenocarcinoma. ‘2Pancoost tumor is hitologically squammous cell. @Most common variety associated with paraneoplatic syndrome | : small cell variety. ®Most common vareity associated with hypokalemia : Small cell (presumably d/t ACTH) Most common variety associated with hypercalcemia ‘Squamous cell (presumably dit PTH) Histological vareity most responsive to chemotherapy ‘Small cell Histological variety response to Radiotherapy : Small cell Histological vareity associated with best prognosis Squammous cell Note ?ancoost tumor is an example of peripheral tumor that is squammous(Otherwise squamous cell variety is largely central *Small cell Ca are associated with : ACTH, gastric releasing peptide, vasopressin, calcitonin. + Squamous cell Ca are associated with: PTH Ansis B : (Bronchoscopy and biopsy) : Harrison 14th/555, 198; 15th/206; 16%/208 «The screening of lung cancer by means of sputum cytology & chest radiographs is not very effective'-H"™¥/255 + Once signs/symptoms or screening studies suggest a diagnosis of bronchogenic carcinoma it is necessary to establish a tissue diagnosis of malignancy. From the options provided tumor tissues can be obtained by =a brochial or transbronchial biopsy during fibreoptic bronchoscopy. CT guided FNAC Fibreoptic bronchoscopy with a brochial or transbronchial biopsy isthe better option here as it also allows direct visualization of the tumor mass The algorithm on page198- Harrison 14th shows that “The first investigation while investigating a case of haemoptysis ‘should be "X-Ray chest’ +Once X-Ray chest suggests bronchogenic carcinoma (i.e. suspected mass) the next investigation. -should be Bronchoscopy *An HR-CT should be done only if bronchoscopy is negative. In this question we already suspect the diagnosis of bronchogenic carcinoma. The investigation protocol, therefore expects us to proceed further from this point, hence a bronchoscopy should be the next investigation, ~HRCT and guided FNAC is done only if bronchoscopy is negative. - As TB has already been ruled out sputum cytology is not the investigation to be done. Answer is A (Pulmonary tuberculosis) : CMDT 2009/246; 2001/.301, 302; CMDT 203/257 All the features mentioned in this question are in favour of pulmonary tuberculosis. Negative sputum cytology:If this is putting you in trouble, rest assured ~'a negative sputum cytology does not rule out pulmonary tuberculosis'-CMDT™"302 In fact, there is a definite set for patients of 'suspected TB with negative sputum smears, these patients are11208 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 Qu7. Ques. Qus. Q120. qin usually investigated by brochoscopy as the next diagnostic step, brochial washings being particularly helpful Here, I would stress that. Defintive di {TB + Does not depend on sputum cytology but, + Itdepends on recovery of Mycobacterium TB in cultures or identification of organism by DNA probe. repeat "demonstration of acid fast bacilli on sputum smears does not confirm a diagnosis of TB". ~ Since saphrophytic and non tuberculous mycobacteria make colonize the airways or cause pulmonary disease, Itis sputum culture with demonstration of M.TB that is diagnostic. Answer is D (Bilateral renal artery stenosis) : Harrison 19°/1763 Pulmonary edema with normal PCWP suggests the diagnosis of ARDS. *High altitude, narcotic overdose and cardiopulmonary bypass are all causes of ARDS with incompletely understood mechanisms Please go through page nos. 484 and 193 H'* or 1524 and 202 H'* fora complete list. ‘Bilateral renal artery stenosis is nota cause for ARDS. Answer is C (Respiratory and metabolic acidosis): Harrison 17/1590, 288, 289; See text below * ApH of 7.2 indicates acidosis (pH <7 is acidosis) + Increased PaCO, suggests respiratory acidosis’ or compensatory response to metabolic alkalosis. * Decreased HCO,’ suggests metabolic acidosis’ or ‘compensatory response to respiratory alkalosis. Had it been a primary case of metabolic acidosis alone - respiratory compensation would have caused decreased PaCo, (here PaCo2 is increased), -absence of compensatory response would have shown normal PaCo, Had it been a primary case of respiratory acidosis alone, ~ a compensatory response would have caused increased HCO,” (here HCO, is decreased) -absence of compensatory response would have shown normal HCO, The given blood gas analysis profile thus can not be explained by either metabolic or respiratory alkalosis alone, with or without compensation, It can only be explained by a combination of both respratory and metabolic acidosis Answer is C (Respiratory alkalosis) : + apH of 7.5 indicates alkalosis (pH> 7.3 is alkalosis) + decreased PCO, indicates respiratory alkalosis + (HCO, status is not mentioned. However it is likely to be decreased as a compensatory response) This isa simple case of ventilator induced hyperventilation causing respiratory alkalosis, Answer is A(LV. fluids) : Harrison 18/2031 Inferior wall MI suggests that the patient has right ventricular infarction, R.V. infarction should be considered whenever a patient with inferior wal infarction exhibits signs of low cardiac ‘output and raised venous pressure with or without hypotension, Therapy essentially consists of volume expansion or fluid loading to maintain adequate R.V preload, and efforts to improve left ventricular performance with a tendent reduction in PCWP and pulmonary arterial pressure, Answer is C (Echocardiography) : Harrison 19°/1546 ‘The history suggests the diagnosis of ‘Mitral valve prolapse'(MVP). Investigation of choice for MVP is Echocardiography. Mitral Valve Prolapse in short “Also known as ‘Barlow's syndrome® or Billowing mitral valve® or Floppy walve syndrome®. + Itis most common in females? + Inheritance in familial cases is autosomal dominant® + Patients are - usually asymptomatic - may present with non specific chest pain, dyspnea, fatigue and palpitations.Qi. Q123. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 1209 F Auscultatory findings are characteristicand most important ~ Characteristic mid systolic® or late systolic non ejection® clicks® which may be multiple® Late systolic ejection murmur (Often but not always) ~ Accentuation of findings by Valsalva and standing. © - Diminished by squatting and isometric exercises. + Diagnosis Investigation of choice is echocardiography. & ECG in most cases is normal. ° + Complications -MRO - Transiant ischemic attack @ -Arrythmias® = Infective endocarditis ® = Sudden death @ Answer isD (Coaretation of aorta) : Harrison 194/525 Intermittent claudication, dizziness and headache are all suggestive of coarctation of aorta + Clinical presentation of coarctation of aorta is characteristic : = Most patients are asymptomatic - Symptomatic patients usually present with : + Headache, dizziness, 2 + Epistaxis + Cold extremeties, and weakness in the legs @ + Claudication with exercise ® + Hypertension in upper extremeties with marked diminition of pulsation in lower extremeties. 2 + Mid systolic or continuous murmur over anterior part of chest and back © + Enlarged and pulsatile collateral vessels in intercoastal spaces anteriorly in axilla or posteriorly in interscapular area. ° + Upper extremety and thorax may be more developed than lower extremeties. @ + ECG shows L.V. Hypertrophy? Radiography: a. Indentation of aorta at site of coarctation and '3 sign’ on paramediastinal shaddon are almost pathogenic. @ ’b. Notching (erosion) of inferior surfaces of ribs. @ + Complications a. Cerebral aneurysms and haemorrhage ® », Rupture of aorta ¢. Left ventricular failure? 4. Infective endocarditis @ ‘Treatment : is surgical resection ° of ‘coarctation’ and end to end anastomosis ‘Remember that HT may not be corrected even after surgical correction of the ‘coarctation’. © Few other questions : Most common site® of coarctation of aorta: distal to origin of left subclavian artery.® ‘Most common associated cardiac anomaly? : bicuspid aortic valve. © May be associated with @ Turner's syndrome. @ Answer is B (Left aterial hypothrophy) : Ghai 50/296; Harrison 19%/1521: Read text below LA has two outflow tracts in this condition viz. -intoL.V. through mitral valve into R.A. through ASD + With two outflow tracts the resistance against which the L.A. has to pump is decreased - this explains absence of L.A. hypertrophy + Right atrial load, however is increased and so isthe load to R.V. and Pulmonary vessels - this explains R.A. and R.V. hypertrophy as well as pulmonary hypertension ‘Some important points about ASD ‘+ Most common form of ASD is : Ostium secundum @ + Lutembacher syndrome is : ASD + Mitral stenosis + Heart sounds: S, is widely split and fixed. @1210 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001 Qua Qus. Qu. Qn. + Murmur : Shunt Murmur is absent ie. murmur is not due to the shunt. @ Murmurs produces are flow murmurs due to increased flow through the ‘Tricuspid valve (delayed diastolic)® and Pulmonary valve (ejection systolic) @ + ECG :- with right axis deviation and R.V.H. suggests Ostium secundum defect © - with left axis deviation suggests Ostium primum defect. @ Note that : + Patients with ASD are generally asymptomatic © + Congestive cardiac failure is rare in patients with ASD (it almost never occurs in patiens with T.O.F.)® + Infective endocarditis is very rare in patients with ASD ( because pressure gradient is very less) ° «In ASD pulmonary flow is greater than sytemic flow (Hilar dance and pulmonary plethora are seen) @ ‘High incidence of ASD is seen in patients with Down's syndrome. Answer is A (Lung) : Harrison 19/816; 179/791 Pieces of vegetation may breakof and cause emboli. Needless to say, however, + Emboli originating from left side of the heart: will enter the systemic circulation (forward flow) and affect organs like spleen, kidney and brain, causing infarcts, abscesses and mycotic aneurysms. + Emboli originating from right side of the heart will enter the pulmonary circulation and produce lung abscesses. Mitral valve vegetation would obviously not go to the lung, as that would involve a ‘backward flow’. Answer is A (Septic Infarcts to lung) : Harrison 19/819 See the above question, Answer is C (Cardiac temponade) most probably : Harrison 19%/1573-74; References alongside Guys ! now this is one of those kind of questions that is certain to get on to your nerves. Iwill tell you how + There is a table on_Harison pag (14h)1336 or 151367 that says Kussmaul's sign is present in constrictvie pericarditis but nt in Temponade or R.V. M.L. or R.C.MLP. All I can advice you here is not to go by this table. Coming tothe text thus + Harison page (14th)1283 or (1th) 1257 says : "Kussmaul sign is a frequent finding in patients with R.V.M.L. or constrictive pericarditis". Going by this line we narrow down our doubts to R.C.M.P. and Temponade, + Harrison page (14th332 or (13th 1363 says that Kussmaul's sign may be seen in R.C.M.P. but it does not mé hhow frequent itis in this condition. + Harrison page (sth) 336 or (15) 1367 says "a positive Kussmaul’s sign is rare in Cardiac Temponade”. Now friends let us draw an inference fr stuff ‘Kussmaul's sign can be found in all the above conditions. However, -Itis frequent with constrictive pericarditis and R.V.M1. = Not so frequent in R.C.MP. but definitely present - Rare in Cardiac Temponade So the most appropriate answer here should be Cardiac Temponade. However, take your time to figure this out and rely on your own inference. Answer is C (Cardiae Teponade) : Harrison 194/1573-74; API 6th/43] Cardiac Temponade should be suspected in any patient who has @ rapid down hill course and exhibits the triad of: 1. Rising systemic venous pressure 2. Falling Arterial pressure 3. Quiet heart (distant heart sounds) ther known features include Tachycardia and pulsus paradoxus. Also, blunt trauma is an important cause of cardiac temponade. ‘The patient in question presents most ofthe above features, following blunt trauma to the chest Most likely diagnosis therefore is cardiac temponade jings and asked to distinguish between cardiac temponade and constriQ128, Q129. Q130. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 12 Few guidelines to answer these kind of questions Ifthe question talks about any of the following, mark your answer as "Cardiac Temponade' a. Elevated J.VP. with a prominent x-descent y-lescent is dimunitive or negative) b. Electrical Aliernans . Pulses paradoxus : Paradoxical pulse is the hallmark of cardiac Temponade. Ifthe question talks about any of these, mark your answer as ‘Constrictive Pericarditis’ a. Elevated J.V.P. with a prominent y-descent (along with a prominent x-descent) b. Kussumaul's sign, which is rare in cardiac temponade ¢. Pericardial knock, which is rare in cardiac temponade ‘The answer is B (Ferritin) : Harrison 191h/628 Iron is stored as Ferritin, Ferritin found in circulation, isin equilibrium with tissue Ferritin, The serum measurement of Ferritin correlates well with the level of total iron body stores. ‘Serum Ferritin levels fall as iron stores are depleted. + The first stage of iron deficiency is depletion of iron stores, wh ferritin levels only. As long as some stores are still available, the other indices ic. SI, TIBC and red cell protoporphyrin levels continue to be within normal limits, Alsoas the patients is not anemic as yet, RBC morphology is essentially normal. is associated with a decrease in serum Answers A (HDA) : Harrison 19°/634-35 Sickle cell anemia is the prototype of Structural Haemoglobinopathies® characterised by production of structurally abnormal Hb chain, It is caused by substitution of valine for glutamic acid at position 6 of B chains. ? HDA isa, B.. Itthus needs to have both «and B chains. B chains however are defective in sickle cell disease such that In hetrozygotes or sickle cell trait : 40% chains are defective -In homozygotes or sickle cell disease : 100% chains are defective. In other words there are no B chains in sickle cell anemia (homozygos) and therfore no HbA. HDA, isa,8,and HbFis,, There is no underlying defect in chains or ychains in sickle cell disease and hence HBF and HbA, may well be seen. ‘The answer is C (decreased PTT) : Harrison 19*/738; CMDT 20091474; 2001/552; CMDT 2003/516-18 PTT is increased in DIC DIC or Disseminated Intravascular Coagulation, isa complex thrombohaemorthagic disorder characterized by the following sequence of events in general : 1. Intravascular activation of coagulation by both intrinsic and extrinsic mechanism. 2. A thrombotic phase 3. Consumption phase, wherin most coagulation factors and platelets are consumed. 4. Stage of secondary fibrinolysis, at site of intravascular coagulation. Laboratory findings are in accordance with the above pathogenic mechanisms 1. Platelets count, coagulation factors and fibrinogen level : are decreased? or ‘consumed! Asa result of above : The bleeding time as well as the coagulation time both are prolonged ® therefore PIT increased ® Pr increased ® Thrombin time: increased? 2. Increased secondary fibrinolysis accounts for - raised plasmin levels ® - rainsed levels of fibrin degradation product (FDP). ° 3. The thrombolic phase accouns for features of microangiopathic haemolytic anemia. - presence of schistiocytes, spherocytes, burr cells, halmet cells in the peripheral film. ®1212 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001 2 g 3 a & a 8 R rm 8 = 3 = = 2 Q132. Q133. ‘Some question ask + Most important treatment i finding a reversible cause and treatment of the cause ® + Finding in DIC, that correlates best and most closely with bleeding is: fibrinogen level ® ‘Most common site for thrombin formation in DIC is: Brain® (Brain>heart>lung>kidney>adrenal >liver) + DIC isrelated to 2 very important enderine manifestations : a. Adrenals - Fredrich Hausen Syndrome? b, Pituitary - Sheehan's Syndrome.® Answer is A(Henoch Schonlein Purpura) : Harrison 19°/732 The mechanism of ecchymoses or purpura in Henoch Schonlein is vasculitis. There is no thrombocytopenia. Henoch Schonlein Purpura a distinct systemic vasculitis syndrome that affects small vessels (small vessell vasculitis) @ affects usually children @ - the presumptive pathogenic mechanism is immune complex deposition. The most important antibody class seen in these complexes is IgA.® Presentation is with : + Skin involvement elsewhere, «Joint symptoms : Polyarthralgia, most commonly involving knees and ankles. +Gl involvement &: Colicky abdominal pain® associated wih nausea, vomitting and diarrhoea. + Renal involvement 2 : Mild glominelonephritis, Present as proteinuria and microscopic haematuria ® Important Lab findings : Platelet count is normal or elevated.(No thrombocytopenia) IgA levels are elevated® in about one half the patients. Prognosis is excellent & and disease is self limited. Lasts six weeks, and subsides without sequelle (ifrenal involvement is not severe). ipable purpura ® typically located in the lower extremeties, although may be seen Answer is A (Leukemia) : Reference alongside The presence of Pancytopenia and 6% blasts in peripheral blood is enough to support the diagnosis of leukemic leukemia. Presence of splenomegaly eleminates aplastic anemia & ITP as the possibilities. + Splenomegaly & Lymphadenopathy are extremely uncommon in ITP & their presence should lead one to consider other possible diagnosis ~ Robbins si1s + Splenomegaly is characteristically absent in aplastic anemia and if present the diagnosis of aplstic anemia should be seriously questioned - Robbins S615 + Hemotysis does not explain the low WBC platelet count in the patient. + Leukemia: Although leukemia usually presents with an elevated WBC count the presence of Pancytopenia and ‘6% blasts in peripheral blood is enough to support the diagnosis of aleukemic leukemia, Some patiens with aleukemic leukemia present with pancytopenia without circulating blasts. The diagnosis of leukemia in such patients should however be ideally made only once, a marrrow blast count is done and it comes out to be>30%, Answer is C (Myelofibrosis): CMDT/507; Robbins/662: CMDT 2003/490; Harrison 19°/135e-1 + Myelofibrosis isa chronic myelofibrolic disorder, characterised by = fibrosis ofthe bone marrow - Myelofibrosis and ~ consequent compensatory haematopoesis at extramedullary sites such as the spleen - Myeloid metaplasia + Because of the fibrotic nature of this disoder, bone marrow aspiration is generally unsuccesful and yields & “dry tap’. + Tear drop cells are suggestive of extra medullary haematopoesis as in spleen, About mylofibrosis Spleen is markedly enlarged{striking splenomegaly)as itis the principal site of extra medullary haematopoesis Most characteristic are the Laboratory findings and the triad of @ a. Tear drop poikiocytes ¢ b. Leukoerythroblastic blood i. immature leukocytes and nucleated (immature) RBC's @ ¢. Giant abnormal platelets @ Biopsy of bone marrow to detect reticular or collagen fibrosis is essential for diagnosis.[AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 @ 1213 Q134, Answer is C (Cerebellar Haemangioblastoma) : Harrison 18°/899 [rumors associated with polycythemia vera are ‘+ Hypemephroma * Cerebellar Haemangioblastoma + Hepatoma + Uterine fibromyoma Adrenal adenoma *Meningioma +Pheochromocytoma Q135. Answer is D (Obstructive jaundice) : Harrison 174/262, 263, 16%/1814-16 1(283-1);1Sth/1713, 255 Normal total bilirubin is=0.3t0 LOmg/dl; _ - Conjugated = 0.1 to 0.3 mg/dl. - Unconjugated = 0.210 0.7 mg/dl. Normal Alkaline phosphatase =3 to 13 KAU (010 1201U/l) High rise in conjugated bilirubin level is consistant with: Hepatocellular disease( Viralinfective Hepatitis) Obstructive jaundice Haemolytic jaundice is not likely because the direct /conjugated bilirubin level is highly raised. Rise in alkaline phosphatase levels, Patient with parenchymal disease of liver i.e. hepatocellular disorders : may show increase in alkaline phosphatase levels but the increase is only slight to moderate and usually not more than two times normal ~ Obstructive lesion: Siriking increase in alkaline phosphatase is more suggestive of an obstructive lesion In the given question rise in alkaline phosphatase is about 6 to 7 times normal and thus is more in favour of an obstructive cause. Q136. —_Answeris A (Haemolytic jaundice) : Harrison 17 262, 263, 264; 16%/1814-15; Read text below All findings in the question corroborate with a haemolytic picture, + Presence of Urobilinogen in urine rules out an obsrtuctive cause for jaundice. + Decrease in haemoglobin and elevated bilirubin levels are consistant with a haemolytic cause. + Gall stones can be explained by precipitation of bilirubin (Bilirubinate crystals) Patients here is most likely suffering from a haemolytic jaundice. Q137, Answer is C (Esophageal varices) : Nelson 16th/1226 + Most common presentation of esophageal varices is Hematemesis. - "Hemorrhage, particularly in children with portal vein obstruction, may be precipitated by minor febrile, intercurrent illness. The mechanism is often unclear; aspirin or other non-steroidal anti-inflammatory drugs may be a contributing factor by damaging the integrity of a congested gastric mucosa or interfering with platelet function”. + 'Splenomegaly, sometimes with hypersplenism, is the next most common presenting feature in the portal vein obstruction." ‘These statements point clearly in favour of esophageal varices. Q138. Answer is A (Kidney) : Chandrasoma Taylor 2nd/127; Harrison 194/1857,1869 Urinary casts are found when proteins and other organic matter in the renal tubule solidify. ‘The presence of casts in urine is indicative of disease of the nephron. Casts may contain : Protein only : Hyaline casts Erythrocytes : Red cell casts Leucoeytes : WBC cast Tubular cells: Epithelial casts Clinical significance of different cass. a. Hyaline casts : + This is a normal constituent © of urine and has no attached singificance?. + Tom Horsfall protein® is protein secreted by epithelial cells of loop of henle®. This protein may be exerted as Hyaline cast. ° b, RBC cast: are suggestive of glomerular injury «c, White cell casts : are suggestive of interstitial injury and may be seen in interstitial nephritis® Ipyelonephritis®, 4. Broad granular casts: are seen in CRF and suggests intertital fibrosis and dilatation of tubules. . Pigmented muddy brown granular casts : are suggestive of ischaemic or nephrotoxic injury ®i.e. Tubular Necrosis 81214 © AIPGMEEXAMINATION ANSWERS AND EXPLANATIONS -2001 Q139, Q 140. Quai. Qi. Answer is C (IgA Nephropathy) : Harrison 19°/1840 While, IgA Nephrapathy presents within three days, presentation of poststreptococcal GN is usually delayed to ‘more than 10 days'. Beware !! there isa big catch in this one ... Read the following two text facts very cerefully - + IgA Nephropathy : The disease affects children and young adults. Patients with IgA nephropathy typically present with gross haematura, often 24 to 48 hrs. after a Pharyngeal or gastrointestinal infection, vaccination or strenous exercise, + Poststreptococeal GN : Most commonly encountered in children 2 to 6 years old. Glomerulonephritis develops ‘on average 10 days after pharangitis and two weeks after a skin infection with a nephritogenic strain of gp. A Haemolytic streptococi. Those with overt disease present with gross haematuria (red or smokes urine) headache and generalise symptoms such as anorexia, nausea, vommitting, malaise. Thecruxofitis: + Both are common in children Both may present after upper respiratory tract infection. + Both present with gross haematuria, ‘But while, IgA Nephropathy presents within three days, presentation of poststraptococcal GLN is usually delayed to more than 10 days’. As the patient here presents within 3 days diagnosis is IgA nephropathy. There was another similar question in the All India 2000 paper where the patinet with similar features presented fifteen days after Upper Respiratory Tract Infection. That was a case of PSGN Both IgA and poststraptococcal GLN have important topics, do flip through them. Answer is C (TB) : Ghai Sth/385; Harrison 16%/2492; 14th/2436, 15th/2483 Thus CSF report in question gives a classic picture ofa case of a tubercular meningitis ‘Typical features are * Cells : Mononuclear cells (Except early infection when PMN cells are seen). + Protein: Increased above 40mg/100ml. @ + Sugar : Usually reduced to less than 2/3 of blood sugar. © + Chloride level: Increased but usually less than 600mgial. (Normal C= 113 meq/kgH,0).° [Important points about TBM In TBM exudate is mainly basal (basal brain is involved). Subarachanoid space is involved by the exudate (i. Subarachanoiditis is present). Involvement is mainly ofthe leptomeninges ic. Pia-arachanoid. Duramater is usually spared. 2 Answers A (Lipohyalinosis of penetrating arteries) : Harrison 174/2519; 16 2378; 15th/2370 Lacunar infarcts are caused by Lipohyalinosis of penetrating arteries. Lacunar infarcts are small infarcts in the deep white matter of the hemisphere or brainstem, They are usually due to hypertension induced lipohyalinosis or arteriosclerosis of small penetrating arteries rather than due to large artery atherosclerosis or cardioembolisms Answer is C (Parkinsonism) : Harrison 17/2550; 16%/2406; I4th/ 2356, 15th/2399 Parkinsonism is characteristically associated with a triad of: 1. Rigidity 2. Bradykinesia 3. Tremor at rest, A characteristic disturbance of gait and posture is seen - ths explains slowness of movements ‘A depressed mood is common and an impairment of cognitive functions sometimes amounting to frank dementia is frequently evident in advanced cases - this explains the memory loss present in the patient The answer is Parkinsonism undoubtedly. Quick Revision arkinsonims is caused by a disturbance in substantia nigra.® + Tremor is typically at rest? with frequency 4- 6 Hz? * Tendon reflexes are unaltered? + Plantar reflex is typically flexor® + Gait is festinating gair®,Q143. Qua. Q 14s. Q146. Qua. Qua. AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 1215 Answer is B (Peripheral neuropathy) : Harrison 16°/2314; I4th/2167, 15th/2274 “Inexplicably sensory changes never occur in Wilson's disease (except for headache)" = Hlarson Answer is B (Supranuclear gaze palsy) : Harrison 17/2559; 16°/2414; 14th/2360, 15th/2403 Guys this is one of the favourites of our AIIMS/AI Examiners. This question has too frequently been asked in these examination to be overlooked. ‘The answer is Progressive Supranuclear palsy or Steel Richardson syndrome. ‘Steel Richardson syndrome is a degenrative disorder where in there occurs loss of neurons in parts of our CNS Which are involved with maintenance of posture & equilibrium, namely the Mid brain, Pons, Basal ganglion and cerebellum. ‘Theclinical features are characteristic "Progressive supranuclear palsy should be considered whenever a middle aged or elderly person presents, with history of repeated falls and has an extrapyramidal syndrome accompanied by nuchal dystonia and Paralysis of voluntary downgaze’ Factors which distinguish this from Parkinson's a, marked impairment of voluntary downward gaze and horizontal gaze. ». extended rather than flexed dystonic posturing ® ©. absence of tremor ® 4, poor response to antiparkinsonian medication Answer is C (Trisomy 21) : Harrison 17/2541, 2542; 16%/2399; 14th/2350, 15th/2393 Several genetic factors are known to play important roles in pathogenesis of atleast some cases of Alzheimers disease. Trisomy 21 isone of them. Adults with trisomy 21 (Down's) consistenty develop the Neuropathologic hallmark's of Alzheimer's disease if they survive beyong age 40. Alzheimers disesae in short: Pathologically : Gross diffuse atrophy of cerebral cortex? with resulting secondary enlargement of ventricular system? Microscopically : Senile newratic plaque® containing A B Amyloid? neurofibrillary tangles®. Biochemieally: Decreased in cerebral cortical content of Neurotransmitter mainly ACH®, Decreased ACH levels may be related in part to degeneration in : nucleus basalis of myernet.® Answer is C (Early onset memory loss) : Harrison 17% 2561, 2562; 16%/2403; 4th/2354, 15th/2397 "Memory loss is frequently not impaired until late in the disease’ = Harrison + Hutington's disease is : a degenerative? brain disorder that is genetically determined ® stsomaldominan It's usual age of onset in 4th or Sth decade ® + Neuropathologically the disease predominantly strikes the striatum® & atrophy of caudate nucleus is seen® + The clinical hallmarks of diseases are : a. Chorea® . Behavioural distrurbance & ©. Dementia® ‘+ Memory loss is frequently not impaired until late in the disease, although attention judgement & executive functions may be seriously deficient at an early stage. + Involvement of extrapyramidal symptom (caudate nucleus) may explain cog wheel rigidity Answers A (Pituitary adenoma) : Harrison 17/2206; 16/2086; 14th/1975, 15th/2038 + Pituitary adenomas (Prolactinomas) lead to an excess of prolactin, This inhibits hypothalamic release of LHRH resulting in defective LH & FSH secretion, Defective LH & FSH secretion inturn result in decreased levels of estrogen in females & testesterone in males. This is how prolactin excess can cause hypogaonadism Inmen therefore it can cause decreased Libido, impotence & infertility. This explains this 30 year old male's ‘complaints of lass of erection & his low testosterone & high prolactin levels. In females prolactin excess can cause irregular mensus (amenorrhea) as well a infertility despite regular mensus. + Testicular failure explains both loss of erection and low testosterone levels but not the high prolactin levels Answer is A (Diabetes mellitus) : See below ‘There is just no way that a pituitary transaction can affect the islets of langerhans. Diabetes mellitus has nothing to dowith the pituitary.1216 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001 Q 149. Q150. Qusi Qisz Q.153 Answer is C (Tension Headache) : Harrison 174/ 100, 101; 16%/88; 14th/ 70, 2310, 15th/73 ‘Tension Headache : + Isa chronic head pain syndrome characterised by tight band like discomfort + Headaches is usually generalised may be most intense about the neck or back of the head. + Patients frequently complain of poor concentration and other vague non specific symptoms + May be exacerbated by emotional stress, fatigue, noise or glare. + It is not associated with focal neurological symptoms. The patient in question has distinclty generalised type of headache worsening with stress. Stress being in the form of her two children badly in school. “More so the symptomatology of cluster headache , migraine and trigeminal neuralgia is quiet distinct from that mentioned above, Answer is A (Migraine) : Harrison 174/96, 97; 16°/88, 93; 14th/70,71, 15th/73, 79 ‘Cluster Headache Lateralised?, usually frontotemporal + Lateralized®, periorbital? of Tess commonly may be generalised temporal + All age groups? are affected +All ages above 10 yrs® with peak at 30-50 y | Females® are affected more than males + Male preponderence® (90%). Men affected 7 times more than females. }+ Family history present? + Hereditary factors usually absent? } Presentation : Pain + Presentation: Pain (periodic attacks 1-2/day) ~ often preceded by aura ~ begins without warning? + builds up gradually? = reaches crescendo within 5 minutes? - may lasts for several hours® or longer = lasts for 45 minutes? ~ usually throbbing? but may be dull excruciating, deep, explosive pain but only rarely pulsatile? - onset is after awakening? & quietened by sleep® | - commonly awakens the patients from sleep?| a ted sumptoms include : + Associated symptoms : = nausea, vomiting, diarrhea ‘These are typical and characteristic :@ - photophobia and visual disturbance® in the = homolateral lacrimatoin form of photopsia and fortification spectra? - reddenning of eye? - paraestheisias with tingling and numbness? nasal stuffiness® other focal neurological symptoms? such as - Prosis®, and clumsiness and weakness? = nausea? Answer is C (Migraine) : Harrison 174/96, 97; 16%/90; L4th/2308, 15th/75 Thisis a case of complicated migraine. For details see above question. Answer is A Pituitary Tumor) : Harrison 19*/2339; Robbin's Sth/1170 The features of MEN Il aare - Ca thyroid -Pheochromocytoma - Parathyroid tumor ‘Mucosal and GI ganglioneuroma are a features of MEN II b and not MEN IL Pituitary adenoma are not a feature of any of the MEN If syndromes. They are seen in MEN Tonly. Note that while MEN IIb is very similar to MEN Ita, MEN Tis distinctly different from the MEN Il syndromes Harrison ‘The better option in view of the above facts is pituitary tumor although I must admit that there is something ‘wrong with this question. Don't fiddle with the options however as these are authentic as given in the paper. All of us got stuck at this one and so should you be. Answer is C (Ca lung with ectopic ACTH produetion) : Harrison 190h/2318 ‘As a method of diagnostic workup of any patient wiith suspected cushings we screen the patient with plasma cortisol levels at 8:00 a.m. in the morning. Those with increased cortisol levels are subjected to a dexamethasone supression test. This is used to group etiology of cushings into the following 1. Noresponse or failure of supression : This is due to two main groups of disorders. a. Adrenal hyperplasia secondary to ACTH producing tumor b. Adrenal neoplasia (adenoma or carcinoma)Q154, Q155. Q 156. sz. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001 © 1217 2. Supression Positive : This is due to adrenal hyperplasia secondary to: - ACTH secretion from the pituitary or pituitary adenoma. In the given question there is lack of supression to dexamethasone challenge so option (d) is out. ut of the choices remaining the presence of hemoptosis points towards the diagnosis of carcinoma lung. with ectopic lung ACTH, although both options (a) and (b) are compatible with the other findings. Points to remember : + Most common cause of cushings syndrome is : latrogenic administration of steroids:® «The most common endogenous cause of cushings syndrome is : = bilateral adrenal hyperplasia? duc to hypersecretion of ACTH from pituitary? by non endocrine tumor + Most prominent manifestation of cushings syndrome due to ectopic ACTH produetion is : - Hypokalemic alkalosis® (ote that typical signs and symptoms of cushings may be absent or minimal with ectopic ACTH production Answer is C (Insulin) : Harrison 19°/2419 ‘Diabetic ketoacidosis cannot be reverted without insulin’ - Harrison/2073 ‘The patient in the above question is a clear cut case of diabetic Ketoacidosis, as suggested by increased blood sugar (Diabetic) and presence of sugar & ketones in urine (ketoacidosis) Diabetic ketoacidosis cannot be reverted without insulin. Remember friends that apart fom diabetes the only other common ketoacidotic state is alcoholic ketoacidosis. ‘A plasma glucose estimation usually is enough to deleniate such patients. Most patients have a plasma ‘glucose, levels of less than 150mg/dl. Hyperglycemia may occur but is usually mild, & rarely ifever exceeds 300mg/dl. tis important to know this distinction as, in contrast to diabetic acidosis this syndrome is rapidly reversed by the intravenous administration of glucose. Answer is C (Hypergammaglobulinemia) : Harrison 16*/1946; 14th/1790, 15th/1850 Immune status with Thymoma, cell number & cell medicated immunity are usually intact 2 + These patients are very deficient in circulating B iymphocytes® & pre B cell in the bone marrow Hypogammaglobulinemia? usually occurs relatively late in adult life. Bacterial infection & service diarrhea usually reflect this antibody deficiency, 2 + Frequently have eosinopenia 2 + May develop Red cell (Erythroid) Aplasia. © Answer is € (A.R) : Harrison 19°/1536 Arm span greater than height is suggestive of Marfan's syndrome Aortic regurgitation (A.R.) isa feature associated with Marfans as well as consistant with a diastolic ‘murmur in second right intercostal space. Answer is A (Hemochromatosis) : Harrison 198/2516-2517 ‘All features marked in the question are consistent with the diagnosis of hemochromatosis. Hemochromatosis is a common disorder of iron storage? characterised by an + inappropriate increase in absorbtion of iron from intestine.2 The excess iron in the body gets deposited in various organs producing characteristic symptoms, Organs commonly affected include 1. Liver: Hepatomegaly® —> cirrhosis? —> hepatocellular CAe 2 Skin Iyperpigmentation® 3. Pancreas: Diabetes mellitus? 4. Joints: Arthropathy® 5. Heart: CHF? 6. Pituitary : Hypogonadism® due to impairment of Hypothalmo-pituitary axis by iron deposition. Thus, the association of hepatomegaly, skin pigmentation, DM, heart disease, arthritis & hypogonadism should suggest the diagnosis. Diagnosis: is established by demonstrating an increase in total body iron stores and in particular an increase in parenchymal iron concentration with or without tissue damage?Q158 Q159 Q160 Quist Q 162 Management: Involves removal of excess body iron, Best method : Phleobotomy ® Other method : chelating agent; which are indicated when anemia or hypoproteinemia are severe enough to preclude phlebotomy? Answer is A (Should be done in all eases) : Harrison 17/2675; 16/2522, 15th/2519; CMDT 2001/1024, CMDT 2003/1002 + Thymectomy should be carried out in all patient with generalized Myaesthesia gravis between the ages of puberty and atleast 5S years- Harrison + Thymectomy should be considered in all patients with generalised M. Gravis younger than 60 years of age. + Done even in those cases, controlled by medical treatment : The advantage of thymectomy is that it offers the possibilities of long term benefit. It may diminish or even eleminate the need for continuing medical treatment. This is why it is done even in those cases, controlled by medical treatment. * Done in those cases also, where thymoma is not associated : 85% of patients without a Thymoma, also experience improvement after thymectomy. 55% to an extent that they may achieve drug free remission, This is why thymectomy is done in those cases also, where thymoma is not associated Only 10% of patients with M. Gravis have an associated thymoma. [Thymus is abnormal in approximately 75% but in the majority (65%), the thymus is only hyperplastic and does not have a tumor] + Thymectomy is not indicated if weakness is restricted to extra ocular muscles - CMD 2001/1024 [Harrison 2472 does not give such a clear picture, and says that itis still debatable whether thymectomy should ‘be done in cases with weakness that is confined to extraocular muscles} Answer is B (Candida) The answer is for sure. Nothing really more to write on this one Answer s.. T'msorry on this one. I am not able to get the correct answer for you because we couldn't figure out what the exact choices to this one were. ! have however written the question so that you might still get an idea of the topic which as I have always stressed is as important as the question itself. Go through this topic if you can and check out the supplement for the correct question and the answer. Group of tests done prior to bone marrow transplantation : Bone marrow ransplanaton by Burst & Deeg ‘Most prospective donors are initially typed for HLA -A and HLA-B loci. Donors identified as potential HLA-A and HLA-B matches are then asked to donate a specimen for DR- loci typing. When a donor is identified as a potential HLA-A and HLA-B and a DR match for a given repcipent he is checked for transmissible infectious diseases such as CMV etc Answer is B (Albendazole is superior to praziquentel in the treatment of above condition): Katzung 81/905 Although Albendazole and Praziquantel are both effective in treatment , albendazole is the drug of choice for the following reasons: 1. Albendazole penetrates the subarachnoid space better than Praziquantel 2. Albendazole course of treatement is shorter (I week) than that of praziquantel (2 weeks) 3. Albendazole is cheaper 4, Co-administration of albendazole and steriod (to treat inflammation) results in increased albendazole absorption, whereas combined use of prazaquantel and a steroid greatly decreases plasma levels of praziquantel Anticonvulsants (antiepileptic) should be given during drug treatment and probably for an indefinite time afterwards. - CMbr 2001/1458 Corticosteroids are used during the acute phase of cysticercotic encephalitis, if intracranial hypertension is, present. (It is used for the prevention of developemnt of hydrocephalus, and does not have much role once hydrocephalus ia already present.) Answer is D (Misoprostol is Drug of choice in pregnant patients) : CMDT 201/609; CMDT 203/575; Katzung 8th/1068 Its stimulant effect on the uterus makes it cont indicated in women of child bearing age + The prostaglandin analog misoprostol is effective in the prevention of NSAID induced gastric and duodenal ulcer® and is the only agent approved by the FDA for this purpose. CMDT:2001/609Q 163 Q 164. Q165 [AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 1219 + Misoprostol causes a dose dependent diarrhea and its stimulant effect on the uterus makes it contraindicated in women of child bearing age®. Katzune 80/1068 +H, receptor antagonist; - whereas previous recommendation were to administer these agents at least twice a day, a single bed time dose may be just as effective and may elicit better compliance -For uncomplicated peptic ulcers, H, receptor antagonists may be administered twice dsily or once daily at bed time, with equivalent efficacy- CMDr 2001 Katsung + Proton pump inhibitors - They are superior to H, receptor antagonists and to misoprostol in the healing (Omeprazole) of NSAID induced gastric ulcer. ~ Compared to H, Receptor antagonists, proton pump inhibitor provide faster pain relief and more rapid ulcer healing. + Alternate pharmacological approaches to failure of an H, blocker include : - using a higher dose of the same H, blocker. - switching to another H, receptor antagonist + switching to a proton pump inhibiter °(Omeprazole) Answer is C (IV E stage) : Meningot 10th/1181 Gastrointestinal lymphomas are staged using a modified Ann Arber Cla TE: Tumor confined to small intestine IIE: Spread to regional lymphnodes IIE : Spread to non resectable nodes beyond regional nodes IVE : Spread to other organs fication : Answer is D : (Subthalmic Nucleus) : Harrison 17/2563; 16°/139; 14th/I14, 1Sth/125-26 The patient's abnormal movement is ‘Hemiballismus'. Hemiballismus manifests as sudden and often violent flinging movement of a proximal limb usually an arm, Hemiballismus develops due to lesion in the subthalamic nucleus. Remember: ‘Abnormal movement ite of lesion 1. Chorea * Caudate nucleus and Putamen (striatum) 2 Athetosis + Lentiform nucleus (Globus pallidus) 3. Hemiballismus + Subthalamic nucleus 4. Parkinsonism + Substantia nigra Answer is B (PT is increased) : Harrison 19th/732; Chandrasoma Taylor 2nd/419 PTs not effected in hemophilia. I athway Extrinsic pathway Ix Ix — x vit mt v x 1 | Prothrombin | 11 PIT + Clotting Thrombin Pr Thrombin | time + (Prothrombin | Thrombin. time I Fibenogen 1 time) ime Fibrin + Thrombus1220 © AIPGMEEXAMINATION ANSWERS AND EXPLANATIONS - 2001 Q166. Q.167 Q 168. Q.169 ‘SUI Qi7 Asis evident from the figure PITis prolonged with deficiency of factors : X11, XI, 1X, VIII Il, Land Thrombin PTis prolonged with deficiency of factors : Vl, V,11, land Trombin Haemophilia A occurs due to deficiency or reduced activity of factor VII (antihaemophilic factor) Factor VIII is involved in the intrinsic pathway which is measured by PTT and not in extrinsic pathway whic is measured as PT. ‘Therefore itis PTT whichis affected (increased) and not PT (unaffected) Answers A (Barotrauma) : Harrison 19°/1716 ‘Complications of endotracheal intubation and positive pressure mechanical ventilation include Pulmonary complications : Others 1. Barotrauma 1. Malnutrition 2 Nosocomial pneumonia 2. Decubitus ulcers ® 3. Oxygen toxicity? 3. Venous thrombosis @ }4. Tracheal stenosis @ 4, Depression S. Deconditioning of respiratory muscles | Gastrointestinal complications: 1. Stress ulceration? 2. Mild to moderate cholestasis @ ‘The Answer is A (Exudate seen in Basal Cisterns) : Cranial MRI & CT; Lee Rao & Zimmer Man -4th/479 * In Tubercular Meningitis: Basal Cisterns are most frequently affected, although often sylvian cisterns and other subarachnoid spaces may be involved. The Basal Cisterns are obscured by presence of inflammatory tissue exudate. * Hydrocephalus is communicating & is usually present. i. it does not improve even if ATT is given. * Calcification is commonly seen in the meninges at the base of the brain. * Ventricultis may be seen, but it is not common, The Answer is B (Libman Sack’s Endocarditis) : 0.8) & 82/AI-2000 ‘Vegetations in Libman Sack’s endocarditis occur on surfaces of cusps. Both surfaces may be involved, most common being the undersurfaces. ‘The Answeris A (Sorting out of eases on availability of medical resources and severity of patients conditio Dorland's Medical Dictionary / 1738 ‘Triage is a french word for ‘sorting’. It is - “The sorting out and classification of casualities of war or other disaster, to determine the priority of need & proper place of treatment.” ‘As we can see, the choice A seems to fit in the most. Patients need not be divided into 3 groups. They can very well be divided into 2 or 4 groups. Tt does not only deal with casualities of War, but also includes other disasters, like earthquake etc. And also severely injured patients need not be the first to be attended to, they can be airlifted to the desired hospital (after being given first aid ofcourse), where the facilities for complex procedures exis. Answer is A (Zenker’s diverticulum) : Dhingra 3rd/330 Zenker’ diverticulum isa pulsion diverticulum, where pharyngeal mucosa® herniates through the Killihan's dehiscence? (a weak area between two parts of Inferior Consirictor®). ‘Age : These condition is usually seen after 60 years of age (elderly) ‘Symptomatology + Dysphagia? : As mouth of the sac is wider than the opening of esophagus, food preferentially enter the sac. When the pouch gets filled with food, it presses on the esophagus & produces Dysphagia. & + Gurgling Sound? is produced during swallowing, + Cough & Aspiration pneumonia? : food eaten over the last few days® may regurgitate as it colleets in the pouch causing cough and aspiration pneumonia, + Malnutrition? ; Patient is often malnourished due to dysphagia.Qim. Qin. Q173. Qi7. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 Answer is B (Middle third) : Harrison 14th/568, 15th/S79 + Squammous cell CA & Adenocarcinoma are the commonest types of Carcinoma eosophagus: ~ Squammous cell CA is the commonest type in INDIA. & ~ Adenocarcinoma is the commonest type in most western countries & is increasing in incidence @ + Squammous cell CA is the commonest carcinoma that often affect upper 2/3 of the esophagus. ® = Commonest site of squammous cell carcinoma middle 1/3rd. = + Adenocarcinoma is the commonest type of carcinoma that affects the lower 1/3 of esophagus 2 = This is so because, the carcinoma that arises in Barrets esophagus is an adenocarcinoma. ® + According to Harrison Ses : Cervical esophagus is affected in : 15% Middle 1/3rd 345% Lower 1/3rd :40% Commonest site of carcinoma eosophagus is middle 1/3rd of eosophagus. Answer is B (Hypochloremic alkalosis) : Bailey Love 22nd/674, 23rd/899 + Characteristically first born male infants® are most commonly affected (Males > Females)? + Onset of symptoms, has its, peak incidence between the third & sixth weeks of life? and itis almost never resent at birth + Most common presenting symptom is vomiting? & accounts for the hypochloremic alkalosis. + The procedure of choice is a Halsted's operation® & not a Heller's myotomy. - Heller myotomy is the procedure of choice for achalasia cardia, ® Answer is A (Truncal vagotomy and antrectomy) : Bailey Love 23rd/'908 ‘The question here strictly specifies recurrence as the major problem ‘Recurrent duodenal ulcer’. Hence a procedure witht the minimum recurrence rate, would logically be, the best operation. ‘Truncal vagotomy and antrectomy is therfore the best answer, as this has the minimum recurrence rate. Other questions = ©. Operation with maximum reduction in acid production ~> Truncal vagotomy and antrectomy © Operation with minimum operative mortality > Highly selective vagotomy. Note: + In highly selective vagotomy nerves of Latarjet supplying the antrum are preserved. © +A drainage procedure is not required ® : + Operation mortality is lower than in any other definitive operation for duodenal ulceration. @ 2. The most widely used procedure in India > Truncal vagotomy plus a drainage procedure (gastrojejunostomy) is at present the most widely used procedure. Answer is D (ATT is the treatment of choice) : Bailey Love 23rd/1046 Hyperplastic TB : + Infection establishes itself in Lymphoid follicles.A fibroblastic reaction occurs in the submucosa and subserosa resulting in marked thickenning of bowel wall and narrowing of lumen. This, together with involvement ofthe adjacent mesentry, omentum,lymph node, results in the formation of a mass lesion. + Most common site is leococcal region. + Radiology/Barium swallow shows + along narrow filling defect in terminal ileum-Baiey Love + two characteristic signs- Oxford text book 4/3243, + Thickening of the ileococeal valve, a wide open valve accpanied by narrowing of the terminal lium Fleschner Sign + Fibrotic terminal iluem opening into a contracted caecum-Sterlin sign + Contracted coecum and shortening of ascending colon-231/Schossber's Tuberculosis. + Cephalad retraction of eaecum - Chapman Treatment —*When patient has not developed obstructive symptoms : Treatment of choice is Chemotherapy i.e, ATT and it may cure the condition. *When obsrtructive symptoms are present : Treatment of choice is operative management with ileococcal resection. + Well guys, so as you can very well understand, choices a, b & c are certainly correct so that leaves us with choice.‘1222 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 Q.175 Q176. Qi7. + Although ATT can be summed up as the treatment of choice if obstruction symptoms are not present, certainly not so if obstructive symptoms are present Ipersonally have excluded 'ATT is the treatment of choice’ because it does not take care of the whole spectrum of disease which undoubtedly includes obstructive symptoms as well, But there are many who believe, that most cases of Hyperplastic TB are managed only conservatively with ATT which could therefore be referred to asthe treatment of choice. Mind you FRIENDS this isan often repeated question. Better figure it and on your own - Tvechecked Love & Bailey, Das Text Book of Surgey, Harrison & CMDT, Chapman. The rests all open for you. is Answer is C (Intestinal pseudoobstruction) : Harrison 14th/1650, 15th/1697 Air fluid levels are unusual in intestinal pseudoobstruction and should raise the possibility of mechanical obstruction.- Harrison'®*/1650 Intestinal pseudoobstruction is an acute or chronic motility disorder, characterised by distension and dilatation of small & large intestine. Underlying cause here is not obstruction but a severe dysmotility resulting in distension, Abdominal X-ray is pseudo obstruction reveals: ~ gaseous distension of large & small bowel and occasionally of the stomach. ~ Air fluid levels are unusual and should raise the possibility of mechanical obstruction. Answer is B (Acute mesentric ischaemia) : Harrison [4th/1652, 15th/1699; Bailey Love 23rd/1074 "The most important clue to an early diagnosis of acute mesentric ischaemia is the sudden onset of severe abdominal pain in a patient with atrial fibrillation or atherosclerosis’ - Harrison ‘The patient in question : is an old man of 60 yrs, who has a history of LH.D. & atherosclerosis & presents ‘with abdominal pain thus leading us towards this diagnosis ‘Major clinical features of acute mesentric ishcaemia are 1. Severe abdominal pain, often colicky & periumbilical at onset, later becoming diffuse 2. Vomiting, anorexia 3. Diarrhoea and/or constipation ‘Examination of the abdomen reveals: Tenderness & distension. Tivo features are important to be observed = Bowel sounds are often normal even in face of severe infarction.° = Gross haemorrhage is unusual °(except in ischaemic colitis)? Gastrointestinal bleeding therefore is mild and accounts for the maroon stools in our patient. Answer is D (Intersphincteric fistula is the most common type): Megregor/77 The majority of anal fistulae start as an anal intersphinctric abscess, secondary to infection of the intramuscular ‘anal gland, resulting in an intersphincteric type of fistula. This is therefore is the commonest type. + The division of Anal fistulae into, Low & High type is based on whether the natural opening is below or above ‘the anorectal ring respectively & not in relation to pelvic floor. + The importance of deciding whether a fistula is alow or high type is that a low level fistula can be laid open Without fear of permanent incontinance as here the anorectal ring is not disturbed. ‘Whereas in case of high level fistula, one must diagnose the case before operation or else one may damage the anorectal ring & cause permanent incontinance. + Goodsal's Rule: - Ifthe opening is anterior to an imaginary line drawn accross the mid point of the anus : fistula runs a straight path directly into the anal canal. - Ifthe external opening is situated posterior to that line : the track will be curved & the internal opening will be single & in the middle posteriorly. An exception to this is, when the external opening is anterior to imaginary line but is more than 1’ inches (3.7Sem) away from the anus. In this case also, the track will be curved and open in midline, posteriorly. ‘The Answer is A(Crohn’s Disease): Read text below * Ca Colon becomes unlikely as this patient is young ~27 years of age. * TB would have been preferred if the question would have specifically talked about India or other developing ‘countries. * Crohn's disease is the most frequent cause of Colo-vesical fistula in the west, and also a common cause in other pparts ofthe world. Itis the most suitable option here.Q179. Q 180. Qisi. Q 182, Q 183. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001 @ 1223 Answer is D (Catheterise, drain bladder and retain the eatheter) : Campbel’s urology 7th/3109 ‘The patient in question is a case of posterior urethral injury Patients with injury to posterior urethera ~ may have attempted to void unsuccessfully before arrival to hospital - on examination Blood is present atthe urethral meatus Idcally, the following course should be followed 1. Patient should be asked not co void pending further evaluation (to prevent extravasation of urine) - therefore MCU is not allowed. 2.A retrogate urethrography should be performed to assess damage - Not an IVP 3. Avoid instrumentation at time of injury and do suprapubic eystostomy as the preferred initial management. ‘Thus none of the option available appear suitable What else can be done? - Campbell +A urethral catheter may be passed into the bladder in many patients with a small, protal tear of posterior urethra, «+ The catheter is maintained for 7 to 14 days +A voiding cystourethrogram is obtained when catheter is removed. ‘The Rationales : * One gentle attempt at passing a catheter is unlikely to convert a partial urethral tear into a complete rupture. + After initial successfull passage of catheter, many of these injuries heal without any stricture or a mild stricture amenable to periodic dilatation. Answer is C (Renal stone) : Clinical Surgery by S. Das Characteristics of a Renal stone that aid in the diagn 4. In lateral view the Renal stone lies superimposed on shadow of vertebral column while gall stones are seen well infront of the vertebral bodies. b. Renal calculti moves with respiration® which can be verified with two exposures, one in full inspire other in full expiration, ¢. Density ofa Renal stone is uniform, while a gall stone is less dense in the centr. 4. Renal stone take the shape of the Renal pelvis® & calyces while a solitary gallstone is usually round and ‘multiple ones are multifaceted. Majority of Renal calculi are Radioopaque? except pure uric acid stones which are Radiolucent®, It is very difficult to asses the exact position ofa radioopaque stone on straight X-ray and a lateral view is, necessary. Arenal calculus has tobe differentiated from [T. Gallstone. ® 2. Caleified Lymphnode. 2 3. Caleified costal cartilage. @ 4, Calcified aneurysm of the abdominal aorta. & Answeris A (Because valveless communication exist with Batson's periprostatic plexus) : - Das text/196 Love & Bailey 23rd/1250 ‘The tumor embolus from carcinoma prostate penetrates into the periprostatic venous plexus with which ithas valve less communication. From here, the tumor cells pass along the vertebral system of veins during coughing or sneezing and reach the pelvis & lower lumbar vertebrae. This has been demonstrated by Batson and the plexus is therefore also known as Batson's periprostatic venous plexus. Remember. Ca prostate is the most common site of primary neoplasm for skeletal metastasis. The bones involved most frequently by carcinoma of prostate are - Pelvic bones @ - Lower Lumber Vertebra® Answer is B (Torsion testes) : Any text book of surgery ‘Elevation of testes reduce the pain of epidydimoorchitis and makes it worse in torsion testes'. Answer is D (Lymphoma) : Bailey 23rd/1278; Robbins Sth/1022 Common tumors of the testes include the following: 1, Seminoma (40%) : most common® : Extremely rare before puberty, & presents between 35-45 yrs. 2. Teratoma (32%): tends to occur a younger age, presenting between 20 & 35 yrs.Q 184, 733/L4B 23rd 719/LaB 733/L6B Q 18s. Q 186. Q187. Q 188. Q 189. 3. Combined seminoma & teratoma : 14% 4, Lymphoma (70%) : constitutes the most common form of teticular cancer in men over the age of 60 yrs. ~ (Robbins Sth/1022) 1 Tumors (1.5%) : Arises at any age; the majority have however been reported between 20 & 30 years of age. (Robbins 5/1022) Answer is D (Reidel's thyroiditis) : Bailey Love 23rd/733, 719; Harrison 19/2299 ‘The patient in the given question is presenting with symptom of Hyperthyroidism. The condition, most unlikely to produce the picture is the one where hyperthyroidism is not a feature, not even trasient. Hoshimoto's Thyroiditis (Auto immune) : In this varient, mild hyperthyroidism may be present initially,° although hypothyroidism is inevitable. Hypothyroidism may develop rapidly or extremely slowly. ‘The initial phase of hyperthyroidism may account for the symptoms in the given patient. Diffuse toxic a goitre or Grave's toxic nodular goitre, & toxic nodule (ie. Toxic thyroid adenoma) are other causes of thyrotoxicosis & thus may explain the symptoms of thyrotoxicosis in the above patient. Riedle's thyroiditis isa very rare disease wherein , the thyroid tissue is replaced by cellular fibrous tissue. ‘The goitre may be unilateral or bilateral & is very hard and fixed. This condition presents with features of ‘hypothyroidism, Hyperthyroidism is not manifested, not even transiently. The differential diagnosis is from an anaplastic carcinoma & can be made with certainity only by biopsy Answer is A Follicular carcinoma) : Read text below The history gives two important clues ‘One : Sudden increase in size of swelling with hoarseness - indicating a malignant transformation. Two : Preexisting long standing multinodular goitre therefore have to look for a malignancy, which is likely to develop in a. long standing multinodul. goitre Incidence of Follicular carcinoma is high in endemic goitrous areas, with long standing multinodular -goitre, possibly owing to persistent TSH stimulation. The answer here therefore is Follicular CA. Remember : Carcinoma that follows accidental irradiation of thyroid gland in childhood is a papillary carcinoma® Answeris A Respiratory obstruction) : Bailey Love 23rd/727 + Most cases of respiration distress following thyroid surgery are due to laryngeal edema.2 + The most important cause of this laryngeal edema is a developing tension haematoma. ° + Most common presentation of a developing tension hematoma is : swelling in the neck with respiratory distress ® + The best and most important management at this stage is : Releasing the tension haematoma by opening the sutures. Ifrelease of tension haematoma, by opening the operative site, does not immediately relieve airway obstruction, intubation of trachea should be carried out, at once. Answer is A (Open immediately) : See question above ‘Answer is A (Open immediately) : See question above Answer is C (Intravenous calcium gluconate and serial monitoring) : Read text below Parathyroid insufficiency isa known complication of thyroid surgery. This is generally due to either : 4. inadvertent removal of the parathyroid gland? or ». vascular injury to the parathyroid end artery resulting in its infarction. ‘The patient presents with : hypocalcemia and its associated symptoms such as tingling, as does this patient in question. Management : Intravenous calcium gluconate or oral Calcium (if associated symptoms are severe) Intravenous calcium gluconate with serial monitoring clearly stands out as the best option.Q190. Qs. Q192. Q193 Q194. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2001 © 1225 Answers A (Immediate laparotomy) A patient not responding to fluids is likely to have a continuous source of bleeding. An exploratory laparotomy to identify the source & appropriate management of the same, would be the best next step. Answer is A (Spleen) : Bailey 23nd/955; Das text book/896 ‘Most common abdominal organ to Rupture following blunt trauma is spleen. Splenic Ruptures should be suspected after any trauma?, particularly ifthere has been direct injury to the left ‘upper quadrant from any angle. b. Initial shock, recovery & sign of bleeding : Initial shock being due to blood loss & recovery due to tamponade which stops further bleeding 2 ©. Delayed case ‘Some signs of shock due to hypovolumia from intraabdominal bleeding such as hypotension, tachycardia, increasing pallor, restlessness & sighing respiration are seen in majority of cases. Answer is D(Intraabdominal bleed) : Read text below Although extradural haemorrhage is the most common intracranial complication following head injury, the Patient in question is suffering from severe hypotension of 90/60, & has tachycardia, which cannot be explained by extradural haemorrhage alone. A patient with head injury, more than often has other significant injuries and a thorough examination of other systems therefore is a prime necessassity. An intraabdominal source of bleed, like a ruptured spleen for example is a more likely cause for hypotension in this patient. Answer is A (Marjolini's ulcer) : Bailey 23rd/148; Bailey 22nd/133; S.Das/108 Marjolini’s ulcer isthe name given to a squamous cell carcinoma (Malignant) which arises in a a. Chronic benign ulcer: eg a venous ulcer, or, . Ascar: eg scar ofan old burn It presents the following character it grows slowly® as the scar is relatively avascular? b. itis painless? as scar tissue contains no nerves? ¢. itdoes not lead to secondries in regional Lymph nodes® as Lymphatic vessels have been destroyed. Answer is B (Atherosclerosis) : Bailey 23rd/227 + The is a case, ofa symptomatic aneurysm suggested by pain as well as a fusiform dilatation of the aorta, + 95% of the abdominal & aneurysms are d/t Atherosclerosis®, - The answer therefore here is Atherosclerosis, An abdominal aneurysm may either be asymptomatic, or may be present with symptoms such as pain: ~ usually felt in the back in lumbar region and in the upper abdomen. - may be felt inthe thigh and groin due to nerve compression. + As arrule, a presence of a pulsatile mass, with symptoms that cannot be reasonably explained by another lesion must be assumed to be d/t aneurysm, Answer is B (Proximal compression causes inerease in heart rate) : Bailey 23rd/231 AV Fistula : All AV fistulas have structural & physiological effects. a, Structural effect : Veins become dilated, tortuous & thick walled (Arterialised)® b, Physiological effect : ~ enhanced venous return results in an increased pulse rate & increased cardiac output?. ~ high pulse pressure® - left ventricular enlargement? & later cardiac failure® may occur. ~ a congenital fistula in the young may cause overgrowth of a limb2, ~ indolent ulcers? may result in the leg from relative ischaemia below the short circuit Clinically : a pulsatile swelling? & a thrilf@ and a continuous brui® may be percieved1226 © AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2001, 196, Q198. Q199. 200. Q201 Nicoladoni's sign or Branham's sign : Pressure on the artery proximal tothe fistula causes : = the swelling to diminish in size. © ~ the thrill & built 0 cease ® = pulse rate to fall @ pulse pressum return to norma Answer is C (Embolectomy is done in all cases): Bailey Love 23rd/255 Thrombosis of Axillary vein may occu a. following excessive excercise ». asa complicating of thoracic outlet syndrome. (It is occasionally associated with a cervical Rib). Presentation : The arm becomes swollen & the superficial veins are distended, ‘Management: rly treatment with anticoagulants may result in rapid resolution. = In severe cases consider: fibrinolytic therapy or streptokinase or TPA = Definitive management of throcic outlet syndrome by resection of the first rib may be required. Embolectomy has not been mentioned as a modality of treatment at all-in Love & Bailey And so even if embolectomy is done, itis certainly not done in all cases. Answer is C (Segmented mandibulectomy) : Read text below Best Management involves resection of the growth along with a healthy portion of mandible on both sides ‘The gap is made good by prosthesis or bone graft. + A commando operation would be too radical forthe 72 year old edentulous mean & therefore will not be recommended. +A hemimandibulectomy will not serve the purpose, asthe tumor is encrouching the midline & therefore is not advisable, + We donot know the extent of infiltration, ofthe tumor, and therefore a marginal mandibulectomy might just not be sufficient to take care of the tumor even with a palliative intent. +A segmented mandibulectomy achieves the above objectives and is the preferred modality, Answer is B (Pleomorphic Adenoma) : Bailey 22nd/475, 23rd/659; Robbins Sth/750 + Pleomorphic adenomas have also been called ‘Mixed tumors'@ They are the commonest tumors of the parotid gland & account for 60% of tumors in the Parotid. + Warthin’s tumor is the second most common salivary gland neoplasm. (Love & Bailey 2ndiold) Answer is A (FNAC) : Bailey Love 237d/760 In any patient with a breast lump or other symptoms suggestive of carcinoma, diagnosis should be made by a combination of: ‘Tripple Assessment a. Clinical assessment Radiological imaging ¢. Tissue sampling for either cytological or histological examination. FNAC- is more than often the first investigation for a tissue assessment. It is the least invasive technique of ‘obtaining a cell diagnostic & is very accurate ifboth operative & cytologist are experienced. (Baley751) However false negative do occur & invasive cancer cannot be distringuished from in situ disease. Ifthe doubt after a cytological assessment persists, itis essential to obtain a tissue diagnosis, which is often taken with a needle biopsy. Only if a needle biopsy result too is non yielding, on open biopsy is carried out. Inthe given question therefore. The first investigation would certainly be FNAC. Had the question, however asked for the Most ‘confirmatory diagnosis the answer could then have been an ‘open biopsy. Answer is € (Lymph node biopsy) : Harrison 15th/362 Here the question talks about the most diagnostic investigation & nor the first investigation. The first investigation undoubtedly here too should be FNAC. But, in view of the high ‘false negatives’ that may be seen with FNAC, and the better diagnostic value of a Lymph node biopsy, a Lymph node biopsy, would be the best answer here. Answer is C (AFP levels always greater than 1000) : Harrison 14%h/S80, [Sth/590; Chandrasoma Taylor 2nd/650 Fibrolamellar carcinoma differs from the typical hepatocellular carcinoma in that it = tends to occur in younger adults (younger females - Chandrasoma-Taylor650) (equally in both sexes ~ Robbins) = tends to occur without underlying cirrhosis.