Scanned with CamScanner‘oriented Anatomy 7% edition. Page 5. Which type of sensation is carried by pacinian curpuscles? a. Pain b, Light touch c. Propioception Pressure Sensory receptors ‘Senses Freenerve | Allskin, Pain, endings epidermis, some | temperature vvisera or, Meissner Glabrous Dynamic, corpuscles (hairless) skin | fine/tight touch, position sense | Pacinian Deep skin Vibration, coxpuscles layers, pressure ligaments, joints | —— | Merkeldise | Finger tips, Pressure, deep superficial skin | statictouch, position sense Ruffini Finger tipsand | Pressure, corpuscles joints slippage of | ‘objects along surface of skin, joint angle change [Ref First Aid for USMLE step 12019, Page no. 482 6. During childhood period head of femur is known as: ' a a. Apophysis \O¥piphysis | Diaphysis c.Metaphysis ‘2 The shaft of a bone ossified from the primary ossification /which grows as the bone develops. ‘them caloifis. Epiphysial ‘nto. the ic cells. Seer Sas > Stee Minette ores” ‘enter inthe diaphysis doesnot fuse with that formed from the secondary centers in the epiphyses until the ‘bone reaches its adult size. Thus, along scortlag fous eptohaial plates intervene Between ‘ond: D These g “ire eventually replaced by bone at ‘each ofits two sides, dlaphysial and epiphysial. When this ‘occurs, bone growth ceases and the diaphysis fuses with the epiphyses ‘> Epiphyseal end of bone after fusion is known as head of ong bone. > Ref: Moore clinically oriented Anatomy 7 edition. Page no. 22, : RRR SISTED TON Special visceral | HN coronary | MCS) efferent sinus Pudendal nerve Pressur SIRS is hy Physiology 7. Action of aldosterone is 4&,)ncreases the Na+ reabsorption from DCT b. Increases K+ reabsorption from renal tubule ¢. Increases H+ reabsorption from renal tubule d. Increases glucose reabsorption Action of aldosterone ‘D Aldosterone and other steroids with mineralocorticoid activity increase the reabsorption of Natfrom the urine, sweat, saliva, and the contents of the colon. 2 Thus, mineralocorticoidscause retention of Na+ in the ECF This expands ECF volume. 3 In the kidneys. they act primarily on the principal cells (eels) of the collecting ducts. © Under the influence of aldosterone, increased amounts of Nov are n effctechanged for K+ and He inthe renal tubules producing a Ke diuresis and an increase in urine acidity. ‘> Ref: Ganong's review of medical physiology 23” Excatonitecemas a _ 8. Third heart sound is present in all of the following condition except b. Children d. Mitral regurgitation a. Pregnancy EMitral stenosis Heart sounds: 3 St: mitral and tricuspid valve closure. Loudestat mitral area 2 82: aortic and pulmonary valve closure, Loudest at let upper sternal border. 'D $3: in early diastole during rapid ventricular filing phos? sociated Wi Tereosel Ang pressures i! “regurgitation, HF) and more common in dila es (out canbe normal_in, children, young dus, on! pregnant semen), > S41 Tate diastole (“atrial kick"). Best heardat apex with patient in left lateral decubitusposiion. High ati! presse, Associated wich ventricular noncompliance (2 hypertrophy).Left atrium must push against stiff LV wal! Consider abnormal, regardies of patient age. >_ Ref: First Aid for USMLE step 12019. Page no. 285 Which neurotransmitter is present neuromuscular junction? a Dubutamine —b)Acetylcholine NMDA 4. Glutamate Scanned with CamScannernate Scanned with CamScanner415.Complement activation is occurs in which of the following type of hypersensitivity reaction? ‘a. Type I hypersensitivity reaction Type Il hypersensitivity reaction ts. Il hypersensitivity reaction d. Type IV hypersensitivity reaction Scanned with CamScannerScanned with CamScannerCIEL ——————— Summary of Major Primary Glomerulonephritides Moorea — Oren ene woos — ve ange — : (poner psa Civ nephees s bereweytong Foca genta Necrrom syncrome Unknown ‘Focal nd segmental Focat iat + C3in oes of foot processes: ‘cera ROE ‘econ ect cere an hyn YC wothela erie ore poe emtrancpratiernee Neghrcnepteoic mune compler Mesangial priferaive or «WG-44 Ch Clare Subordo dapat censors once ‘menbrarapetirame Ot ro (pate of protean. ee 2 (at tucking sug owen ‘kaoutoty, murat Mesangial preterabex—CH.na CigarCh Dense Gaps seca eal tote cman puay oh — wa o 17.Virchow’s triad consists of following except a Hypercoagulability b. Turbulence of blood flow GQreucocyrosis d. Stasis Virchows triad meee ’. Metastatic calcification ¢. Idiopathic calcification d. Degenerative calcification 19.0 patient with abdominal trauma had severe splenic injury. He had undergone splenectomy and Scanned with CamScannerScanned with CamScanner‘ACEinhiitors | Rena failure, oligohydramnios, hypocalvaria 24,30 years patient presented with proteinuria + and Alkylating agents | Absence of digits, multiple blood pressure 140/90 mmHg. What agent you o_o | will to the patient for increased blood pressure? [Aaminoehcosi des eats detects cardiac | ‘Antiepileptic ieural tube defects, cardiac a. Diuretics LeGaleium channel biokers Bis detec cet pant, skeletal — | c.Beta blockers “d)ACE inhibitors abnormalities | Selection of firstline of antihypertensive Diethylstilbestrol | Vaginal clear.cel) | (DES) adenocarcinoma, congenital ‘mullerian anomalies Diuretics || [Folate antagonists | Neural tube defects © Heart failure "© Gout or family history of Isotretinoin. Multiple severe birth defects | Prcciren snk ed coat anor [eCithium Bbstein anomalj gig hus ld eatte Mathimazole | Aplasia-cw-congenital e rpatericn Tetracyclines Dislocated teeth, inhibites bone ‘ACE inhibitor or ARBs peo =iaeeasfallire Saeaitaralsenalartery ‘Thalidomide Limb defects (phocomelia, + Post stenosi—— micromelia ‘flipper’ limbs) + Wigh CAD risk + Bregnan Warfarin Bone deformities. fetal | + Diabetes + Hyperkalemia hemorrhage, abortion, * Ghronickidney | * Preexisting dry cough ‘ophthalmologic abnormalities _| 28; > Ref First id for USMLE step 1 2019. Page no. 600. eae 26.Which of the following agent causes optic neuritis? adrenerge ldkers 2 Rifampicin a. = Stableheart failure [= Asthma, COPD, sana + Rost * adieardla,conductin |} © P¥"izinamide SeeEaa rae f ioe Firstline antitubercular drugs with their side mance + Decompensated heart effects failure ae vb ae é + AbnatmaLlipid profile : é ‘Calcium channel blockers Isoniazide Peripheral ‘AST and ALT, > Recurrentstroke | * Myocardialinadequacy, neuropathy, neurologic prevention CHF jes ‘examination * Conduction defect, sick is Sas Rifampicin. Redcoloredurine, | CBC, hepatitis, rash, Platelets, + Receiving blockers os. | * Ischemicheart disease, fulicellness, GI} aST-and ALT ae upset bleeding iy pe problems, kidney Males with prostate failure ee Pyrazinamide | Hyperurecemig, | Uric acid, c hepatotoxicity, | AST, Al ‘Ref: KDT Essential of Medical Pharmacology 7% edition. rash, jointaches | Page no.570. Ethambutol | Opticneurjtis, | Red-green 25.Which drug is contraindicated in pregnancy? tach color,” a.Nitrofurantoin _b, Hydroxychloroquine aspmae? (7ebyclophosphamide 4. Prednisolone pee Teratogentc drugs er Streptomycin Vestibular 2 Mor snap nett at (eon function, efpraneney nephrotoxicity | BUNand cen creatinine. > Ref CHDT 2019. Pageno 292 Scanned with CamScanner31.Which of the following is intraluminal amoebicide? a Metronidazole c Tinidazole b. Diloxanide furoate . Praziquantel Pete ee controls, Measures heritability and influence of ‘environmental factors, (‘nature vs nurture’) ‘Measures heritability and influence of environmental factors ‘© Ref First Aid for USMLE step 1 2019, Page no. 256. 33,1n a screening test, true positive case is a. Sensitivity b. Specificity c Predictive valued. Odds ratio Twin concordance study ‘Adoption study Evaluation of diagnostic tests 'D Sensitivity and specificity are fixed properties ofa test. PPV. ‘and NPV vary depending on disease prevalence in population being tested +e ve 1P FP PPV=TP/ETP | a ~ +FP) rN LIN NPV=TN/(T ra N+EN) Sensitivi | Specificit | Prevalence=( ty=TP/( | y=TN/(T | TP+EN)/(TP is TP+PN)_| N+FP) _ | +FN+EP+TN) Ref First Aid for USMLE step 1 2019. Page no. 257. 34.Which of the following vaccine is not contraindicated in pregnancy? <2 Rabies b. Mumps Poo d. Measles Vaccines during pregnancy Hepatitis A Base decision on risk vs benefit Hepatitis B Recommended in some : ‘Gircumstances HPV — Not} nded [nc 0] — ae Influenza Recomme! inactivated) risk is in MER Contraindi 4 Pee ss, ‘lio ‘May be used if needed } control study Td | Randomized trial — d. Cross-sectional study aa 1 Varicella zoster Scanned with CamScanner1D) Ref First Aid USMLE step 1 2019. Page no. 256. 38.1n Natural history of disease, phase of pathogenesis begins from __a Interaction between agent, host and environment “bUEntry of causative agent into the human body Appearance of sign and symptoms of disease 4. Early diagnosis and treatment of condition ‘Natural History of Disease a Phase = Isperiod before in man (man at risk) + Epidemiological and environment f vs posible b. Pathogenesis: = gins wh ‘in host + Mubiglication of organism, disease_ initiation and ~ Final outcome may be recovery, disabiliyor death = Host may become a cinco case, subclinical cose or 7 Sensory and cedony lvls of prevention ore ‘Screening of disease may improve prognosis and Scanned with CamScannerScanned with CamScanner44.Cadaveric spasm is a. Involuntary muscle contraction 24 hour after death b. Voluntary muscle contraction 24 hour after death c. Involuntary muscle contraction immediately after death Ca Voluntary muscle contraction immediately after death > Gadaveric Spasm (Instantaneous Rigor/ Rigidity, Cataleptic Rigidity) > Definition: Cadaveric spasm is a condition in whichthe muscles of the body which were in a state ofcontraction immediately before death, continue to be so after death without passing through the stage ofprimary relaxation. 2 Ie is @ rare phenomenon of instantaneous rigor, which develops at the -time—of-death with no period of postmortem flaccidity. > Predisposing conditions: It occurs especially in cases of excitement. fear. severe pain, exhaustion, e, electrocution, injury to the nervous system, firearm wound ofthe head, or cmsant poisons, 45.24 years female found hanging on ceiling fan by soul with feet touching ground. There is presence of contusion injury over head. Her husband agreed that they had fight and he hits on head with hard object but he denies killing of her. On neck dissection there is no findings of contusion over the neck. Which dissection you perform first? 4. Bloodless neck dissection from back of the neck Dissection of head first and then to thorax, abdomen and neck ¢. Dissection of chest and abdomen then neck 4, Dissection of anterior neck then expand it to chest andabdomen 2 Internal examination (Evisceration) 3 It is convenient to stort the examination with the cavitychiefy affected. All three major cavities of the body Skull. thorax and abdomen should be opened andeamined os a routine. 'D The choice as to which pare ofbody isto be opened frst— skull: the body cavtiesis left to the dissector. © In suspected head injury: the skulLis opened fist and then the-thorax and the abomen, but some autopsy surgeons ‘are of the view that it should be opened after blood has been drained out by opening theheart. ‘2 In suspected asphyxia! deathsdue to compression ofneck the shull_and_abdomen_is_opened. first. followedby dissection ofthe neck The draining out of blood from neck vessels va the skull provides a comparatively cleaner field forthe study ofneck structures. ‘2 Inall other cases, the thorax and abdomen are openedjirs, ‘and.then the skull 2 Ref: Review of Forensic Medicine and Toxicology. Page no 102. 46.Informed consent includes all except a. Nature of procedure or treatment proposed b, Informed refusal € Reasonable patient 1.) Life expectancy of treatment Doctrine of Informed Consent This doctrine implies an understanding by the patient of _—4= His/her condition or nature of illness . Purpose or necessity for further testing © Natural course of condition and possiblecomplications 4. Nature of procedure or treatment proposed Risks and benefits of treatmene or procedure. F Risks and benefits of alternative treatment orprocedure Prognosis in the absence of intervention ‘n- Buraton and approximate cost of reaement 4. Expected outcome and follow-up. * 2 The information provided to patients easy to understand language and ist ‘complications to enable the patient 0 undergo or decine a procedurtinformeds 2 There is_no need to explain remote or involved which may frighten or confuse result in refusal to take treatment. : > There are no clear parameters laid down quantum of information to be given Therefore, it is reasonable information ing best practices. which physicians are held @ ‘reasonable physician’ , 2 The suits Scanned with CamScannerScanned with CamScannerdoses of naloxone (up to 5-10 mg may be required to reverse the effects of potent opioids) 3. Flumazenit: Flumazenil, 0.2-0.5 mg intravenously, repeated as needed up to a maximum of 3g, may ‘reverse benzodiazepine-induced coma, Ref: CMDT 2019. Page no, 1580-1581 51.68 years male presented with the and rigidity of limbs. Patient also postural instability, decreased activi shuffling gait. Patient is hemodynamically stable, How do you manage the case? Send for CT scan/MRI GB. )aive Levodopa and carbidopa with anticholinergic and advice for follow up ¢. Admit the patient to ward d. Discharge patient without any medications Idiopathic Parkinson's Disease Parkinsonism is a clinical syndrome cl iy T by bradykinesia, with associated ¢ ton 0 of on_arti (rigidity) eremor and loss of postural reflexes. any ai 2 a vt is deeply | causes but the most common is Parkinson's $ are depres Clinical features Bradykinesia, Micrographia Restingtremor | Masked Rigidity facies(hypomi Gait mia) disturbances/po | Reduced eye stural insbability | blinking a Scanned with CamScannerScanned with CamScannerRE 24 years male patient from Chitwan comes to Kathmandu with complain of fever, joint pain and pain and rigidity over neck region for 3 days. On examination there is petechial hemorrhages on the back and_abdomen of patient. Laboratory investigations shows Hb: 12 _gm/dl, TLC: 3,400/cumm, and platelet counts: 70,000. What is the most probable diagnosis? a.Meningococamia ( b. Dehgue ¢.Kala-azar 4. Malaria Dengue > Incubation period 7-10 days. > Sudden onset of high fever chills, severe myalgiasand ‘orthralgias, headache, and retroorbital pain. > Severe dengue ts defined by the presence of plasma leakage, hemorrhage, or organ involvement. > Signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear later in the disease. 2 Leukopenia is characteristic, and elevoted transaminases are in dengue fever. > ‘and hemoconcentration Be re ‘hemorrhagic form of the disease. > The erythrocyte sedimentation rate is often normal in most cases. os ‘> The nonspecific nature ofthe ines: mandates laboratory verification for diagnosis, usually with tgM and IgGELISAs after the febrile phase. 2 Vag rn rai BB a drtectn of 56:22 years male with central obesity, buffalo hump and abdominal stria. ‘mg/dl and there is TACTH level. Most likely cause is a. Ectopic ACTH opm disease Adrenal insufficiency “d-Conn syndrome Cushing syndrome due toa variety of causes: ‘ Primary adrenc! adenoma, hyper = ACTH-secreting pista 55.Diagnosis of pheochromocytoma is confirmed by 2 Acetaminophen is recommended for analgesic ond antipyretic treatment, 'D Plotelet counts do not usefully predict clinically significant bleeding. Platelet transfusions may be considered Jorsevere thrombocytopenia (less than 10,000/mcL) or ‘when there is evidence of bleeding. © Monitoring vital signs and blood volume may help in anticipating the complications of dengue hemorrhagic fever or shock syndrome. > Ref: CMDT 2019. Page no. 1413-1414 Jura YMA and chatecholamine measurement [ b. 5 Hydroxyindolacetic acid level ¢. Serum cortisol level 4. Dexamethasone suppression test Investigations for pheochromocytoma Laboratory findings Plasma fractionated free rmetanephrines 1s the most sensitive test for secretory pheochromacytomas and poragangliomes. 2 Urinary fractionated _metanephrines and creatinine ffectively confirms most pheochromocytomasthat were detected by elevated plasmo fractionated metanephrines Serum CgA is elevated in about 85% of patients withpheochromocytoma and the levels correlate with tumorsize, being higher in patients with metastatic disease 2 Clonidine suppression testing can help distinguishwhether elevated plasma free normetanephrine levels Aarephysiologic or indicative of pheochromocytoma. 2 Imaging: CT and MRI scanning - imaging should be performed only in patients with suggestive laboratory findings, since adrenal pheochromocytomas can appear similar to commonly found benign adrenal adenomas (2- 4% ofall scans). 2 Ref: CMDT 2019. Page no. 1190-1192 is fasting blood sugar level is 130 HH, -rbilateral adrenal atrophy. Most common cause. inoma—result in ACTH, ~ atrophy ofuninvolved adrenal gland. Scanned with CamScannerScanned with CamScanner— nts necessary for normal tissue and cellularfunction. Initially may be reversible 1V fluids Inotropes, diuresis SS Relieve obstruction ‘59.Treatment for acidotic hyperkalemia is ‘2A insulin with glucose b, Sodium bicarbonate © Hypertonicsaline _d. Intravenous potassium ‘manifestations of hyperkalemia da medical emergency and treated bowel syndrome? 2. More commonly occurs in female CB) itis not associated with history of physical oF sexual abuse © Most patient alternate between episodes of diarrhea and constipation d. Commonly associated with dysmenorrhea and fibromyalgia Scanned with CamScannersomman. «sometimes associated with Ss Mie latinprier etic n, congas these patients be 4 ee nefit from psychologically based sical features iY most common presentation a eee aaaree fore “8 usually colicky or cramping inn 9 RE tereiiy chores mee minal bloating worsens throughout the day: the “use isunknown but ‘it is mot due to excessive intestinal current abdominal pain or discomfort on at Teast | ys per month in the last 34 months, associated 1) wo or more of the followin See ent with defecation a re : Onsetassociated witha change" ea of \0_years male P! ‘bdominal’ distensio vestigations 1 ‘onjugated bilirul 5), AST "uentalso have HBSAB BOS id anticHBe 1gM > om: — | ‘ute Hepatitis B with i ‘cute Hepatitis B with LO" 1D Ref: First Aid for USMLE Ste a74 62Severe hypothermia is defined as temperature: Dec b.<30°C ar 4.<34°C 632°C Clinical features of abnormal __core body.63.34 years female presented with the complains of fever, vomiting, headache and neck rigidity for 3 days. On. presentation patient is conscious and hemodynamically stable. Lumbar puncture performed and report shows cell count 1170/cumm (N:60%, L:30%, M:8%, E:2%), CSF glucose: 35 mg/dl, CSF protein: 95 mg/dl What will be your diagnosis based on given parameters? a.Tubercular meningitis b. Viral meningitis tute bacterial meningitis. Fungal meningitis Interpretations of CSF 200-20,000 | 100-1000 | 25-2000 100-1000 | Variably PMNs: mostly mostly mostly increased lymphocytes | lymphocytes _| lymphocytes Tow (<45) | Low (<45) | Normal Normal Normal High (>45) | High (@45) | High (>45) High (>45) | Normal orhigh — Markedly | Moderately | Slightly Normal or | Variable elevated | elevated —_| elevated slightly | elevated | Cloudy Clear/cloudy | Clear | Gram ‘AFB staining | Sterile or | virus isolated J 64.During defibrillation a monophasic shock is 360 J, Tever E | what amount of shock will you use for || SB@\MAsnd | HaFcashing | defibrillating ventricular fibrillation? ypovolemie | BOE tis not shock insulin with | associated with i big30) [Acute Hepatitis | (MEY <26°C | GEMH Acute bacterial Bwith High meningitis 150) ] ray, shore-duration | Surgery 65.Which of the following organism is most ‘over the upper commonly responsible for infection to post- 3 “in the monogement | Splenectomy patient? anunsynchronised | a, Pseudomonas _b. Aspergillus wt? discharge is not neumococcus _—_d, Klebsiella prope nist postsplenectomy infect 1s Postsplenectomy septicaemia may result from ‘Streptococcus pneumoniae, Neisseria _meningitides, Haemophilus influenzae. cherichia coli. . ‘elective splenectomy is planned, consideration should be given to vaccinating against pneumococcus meningococcus C (both S years) ond Hi. i b) (repeated every 10 years). 2 The latter two vaccin monly delivered as 0 preparation. > Yearly influenza vaccination Scanned with CamScanner67.1VU is done for b. Metabolic function of liver © Absorptive function of thyroid ‘nt undergone renal transplant vothrecipient’s broncho-alveolar lavage fuid croscopy Shows presence of buds and sulated yeast cells. Organism responsible fororganization. 1 ‘ 2 Leal erent ‘the hyperacute hour or so), but on occasion when this is per ‘appear y_isodense the cortex, with a swi duce to a mixture of the clot, serum and ongoing unclotted an acute_subdural ‘homogeneously ni jon that spreads “the affected hemisphere. As the clot starts to the density increases typically to >50-60 HU and is us| relative tothe cortex. © Subacute:As the clot ages and protein degradation occurs, the! At some point between 3 and 21 days the density will drop to ~ 35- 40 HU and become: the adjacent cortex, making identification potentially tricky, especially if subdural collections are bilateral Chronic:By definition, it 3_weeks old.The subdural eollection becomes hypodense (black) ond can ‘ypodense (black) reach ~0 | be isodense to CSF, and mimic a subdural Sena aot ape may change to a biconvex one x" ‘Acute on chronic:Acute on chronic subdural hematomas refers toa second episode of acute hemorchage ito a pre- existing chronic subdural hematoma. Ie ypically appears ‘as a hypodense collection with a hematocrit level (located RI csc 70.4 patient following RTA with head injury opens 2 eyes on pain, produce incomprehensible sounds || _ and withdrawal on painful stimuli. GCS score of patient is: a7 a oo 46 pontaneously To verbal command. To painful stimulus— Normal oriented—— conversation, Confused ‘Abnormal Hexion Extension zn] No motor response 1 Total score: 13, Minimum score: 3 3 Ref: Bailey and Love's Short Practice of Surgery 27% edition. Page no. 331 71.Fungating ulcerative suggestive of: 4 Fibroadenoma b.Phyllodes tumor eprcinoma breast d. Inverted nipple Glinical presentation of breast carcinoma 3 Although any portion of the breast, including the axillary tail, may be involved, breast cancer is found most {frequently in the upper outer quadrant. ‘Most breast cancers will present as @ hard lump, which ‘may be associated with in drawing of the nipple or overving skin ‘As the disease advonces locally there may_be_skin involvement with peau dorangeor fragk.uleeration and {fixation to the chest wall This is described as cancer-en- cuirasse when the disease progresses around the chest wal Ref Bailey and Love's Short Practice of Surgery 27% edition. Page no. 873-874. 72.Features of gastric outlet obstructioi @)Aypokalemic, hypochloremic, metabolic alkalosis Hyperkalemic, hypochloremic, metabolic alkalosis. ¢. Hypokalemic, hypochloremic, metabolic acidosis 4. Hyperkalemic, Hyperchloremic, Metabolic acidosis Gastric outlet obstruction 'D The two common causes of gastric outlet obstruction are ‘gastric concer and pyloric stenosis secondary topeptic uleration. ammo" Metabolic effects ‘These are most interesting, as the metabolic consequences ‘of benign pylori stenosis are unique. 2 The of hydrochloric’ acid results loraemicalkalsis. ‘> Initially the sodium and potassium may be relatively normal. However, 0s dehydration “more mass over breast is 2 2 Profound metabolic abnormalities arise, partly > renal dysfunction, > Initially, the urine has a low chloride and high bicarbonate content, reflecting the primary metabolic abnormality. ‘2 This bicarbonate is excreted along with sodium, and so Scanned with CamScannermsn ei : not a out Ww inussusception? Most commonly affects the ehildre snonths to 10 months: Nay must be done to pul obstruction sean Child by normal in between episodes Managed — non-operatively — with. suatic reducHgHliVstagaleliceontastvesie a MOF age Rroup 5 74.2 years male child presented vomiting and not passing stool repeated attacks of screaming and the logs for few minutes in previously wel rT ‘On the emergency he passes maroon and abdominal distension persists and child ts pale looking, What Is the most common cause? 4, Diverticulitis b. Duodenal atresia d hernia Scanned with CamScannerRef Bailey a7 76.Treatment of choice for solitary toxic thyroid nodule for 25 years female is: a.Radioiodine (~BSurgery ntithyroid drugs 4. Levothyroxine ‘and thus there is minimal risk of delayed R ‘and Love's Short Practice of Surgery 27% ‘edition, Page no, 812 77-Keloid i CH Abundant collagen. ‘be More fibrous tissues ¢ Well responsive to treatment 4. Confined to original site of trauma 7aWhich of the following is xray feature of pneumoperitoneum? a. Ground glass appearance “Ch. Paisence of gas under right hemidiaphragm «Dilated bowel loops 4.Colon cut sign (causes of pneumoperitoneum occurring in children are different from the adult population. ‘erect chest x-ray is the most sensitive plain radiograph {for the detection of free intraperitoneal gas in an ‘emergency setting. 2 On chest xray, any subdiaphragmatic free gas can be seen. 2 Abdominal radiogrophy is routinely done in cases of acute abdomen. The various relevant signs described in an abdominal radiograph are as follows: = ~Cupola/saddlebag/mustache sign — Seen on o supine radiograph. refers _to_ir accumulation Zao Rigier’s sign — Air outlining both sides of the bowe! _wall, = “Lucent liver sign ~ Reduction of liver opacity due to sir located anterior to the liver. Footballl sign — Seen in massive pneumoperitoneum, where che abdominal canigyis outlined by ges = Sitver’s sign — Also called « falciform ligament sign where air outlines the faliform ligament. Inverted V sign — Air outlining laceral umbilical ligaments (inferior epigastric vessels). Doge's cap sign — Triangular collection of gas ‘Morison pouch. + Telltale triangle sign — Triangular air pocket between three loops of bowel + Urachus sign — Outline of middle umbilical ligament. Ref. hieps:// www.nebiznlm.nih.gov/ pmefarticles/ ‘PMC4S35122/ Obstetric and gynecology 79.Tocolytics acts on which receptor? ‘a.al receptor a2 receptor ¢.Bl receptor Scanned with CamScannerScanned with CamScanner83.55 years female presented with abdominal pain and mass per abdomen undergone total abdominal hysterectomy with bilateral oophorectomy. On gross exai ion of ovary there is shaggy wall of tumor with papillary projections. Which tumor marker you will send to monitor recurrence of disease? Classification of ovarian tumors Pathological type —— aoe Primary (80%). ‘Secondary (20%) Epithelial (80-90%) Typical Atypical | (Krukenberg) *Serovs (60% Biniccons (cox) |_Nonepmnetel +Endometrioid (2%) - Ganm-cell{10-20%) — Sex cord stromal (3-5%) - Unclassified Tumor Markers = GA-125 (cancer antigen 125) and CEA (carcinoembryonic antigen) should also bedrawn for the possibility of ovarian epithelial cancer. = LDH, hCG, and a-fetoprotein should be drawn for the possibility of germ cell tumors. ‘Estrogen and testosterone should be drawn forthe possibility of stromal tumors. Follow-Up a + Ifthe final pathology report ofthe enlarged adnexa was benign, the patient canbe followed up in the office ana ‘yearly basis for regular examination. = “Ifthe pathology reportwas carcinoma, then she would be fllowed up every 3 months for the first 2 years and. ‘thenevery 6 months forthe next 2 years with follow-up ofthe CA-125 tumor marker. > Ref: DcDw nok of 7% edition. Page no. 305 . 2 Kaplan ct 2017 Obs Gyne. Page no. 205-208. Z se 84.35 years female wanted to use OCP for family planning. She has history of migraine headache and joint pain. There is also history of PCOS to her mother. Which factor does not allow her to use ‘ocps? (ape b. History of PCOS to mother EMigraine headache —d-Joint pain ‘Diabetes with vascularcomplications Migraine with focalneurologic symptoms B. Diseases of the liver o Active liver disease co Liver adenoma, carcinoma C.Others. o Sickle cell disease ‘Headache ‘Cancer cervix or CIN B. WHO category-3: (risks outweigh the advantages) ‘© Unexplained vaginal ‘Diabetes: | © Pregnancy bleeding © Breastfeeding co Hypentipidemia a 2 q Conpatied weeks) Liver tumors (benign) (Adva on igh sjor surgery or o Breastfeeding. Cs ene pn prolongedimmobilization | (postpartum 6weeks‘° oestrogen 6 months) eee piers dependenineoplasms,eg, | oHeawysmoker(> ee east cancer 20cigarettes/day) ‘©Mild hypertension ‘Gallbladder disease Scanned with CamScannerScanned with CamScannerThe level of fundus uteri at different weeks, aw ‘thebladder by a catheter, the through the opening. “The three-swab test not onlyconfirms aiferentiates it fromureterovaginal and ° cats WEI Migraine agenesis | headache [Antibody is | WHATAuscuttation | TAS meg notformed of fetal heart sounds Previous | SER Metiytene | EIN Z¥ weeks ‘lasseal blue Ipper most swab soakedwith | Ureterovaginal || Pediatrics Fig: Three swab test using methylene blue Interpretation of three swab test urine i ae ‘but dg a 91.Down syndrome is trisomy of chromosome: a2 b.18 13 Genetic disorders by chromosome 3 von Hippel-Lindau disease, renal cell carcinoma ADPKD (P02), achondroplasia, Huntington disease Refi DC Dutta’s Textbook of Gynecology. Page no. 5 Gri-du-chat syndrome, familial 342-352, adenomatous polyposis 90.At which week of gestation size of uterus wit be at | [6 ____| Hemochromatosis HF) | the level of umbilicus? 7 Willams syndromejeysbe a. 30 weeks b.24 weeks [| fibrosis: d 26 weeks d, 28 weeks ee u Wilms tumor, Bog defects (eg, sickle Scanned with CamScannerScanned with CamScanner‘94.Which of the following is correct sequence of sexual maturation in a girl? a. Thelarche > Menarche> Growth spurt : pret = 95.Diagnostic test for HIV/AIDS for 10 months old child. a. HIV DNA PCR test b. Western blot test € IgG antibody to HIV 4. p24 antigen assay ‘96.Pentavalent vaccine is given to an infant as regular immunization program. After immunization infant develops fever and rashes all over the body. Infant is brought to the emergency which drug you will give to infant first at ER? a. HI Antihistaminics b. Corticosteroids ©. agonist 4. Adrenaline {The case is of anaphylactic reaction following pentavalent ‘vaccination caused by pertussis component of vaccine} Anaphylaxis D Sudden release of active mediators with cutaneous, respiratory, cardiovascular, gastrointestinal symptoms. ‘Most common reasons ‘sting, oral medications, idiopathic > Presentation: reactions from ingested allergens are delayed (minutes to 2 hours); with injected allergen, reactions mmedite (more gastrointestinal symptoms) Treatment a. Wilson’s disease .Prophyria ¢ Thalesemia d. Autoimmune hemolytic anemia Scanned with CamScanner” ee _ ears child presented with fever “nas neck rigidity. Lumbar puneimns 8 ah Headache for'3 days. On presentation child ‘sf glucose: 40 mg/dl, CSF protein; 195 done and report shows CSF cell count: 970/cumm, syogenic meningitis b. Viral ae a a ipercular meningitis 4. Fungal meningitis s unconsciouss N:55%, L:40%, Interpretations of CSF 200-20,000 | 100-1000 | 25-2000 PMNs: mostly mostly lymphocytes | lymphocytes Low (<45) | Low(<45) | Normal High @45) | High(45) | High 45) Markedly | Moderately | Slightly elevated | elevated Clear/dloudy | Clear ‘ARB staining | Sterile or virus isolated nose. On examination there is petechlal rashes vresent over the bilateral thigh region. Her Hb; 12 gm%, TLC: inv cstigation shows SES \500/cumm, Platelet counts: 45,000/cum! probable cause is: Hiemophilia ‘mune thrombocytopenic Purpura ‘omin K deficiency leukemia st ae Scanned with CamScannerOrthopedics 100. Bony ankylosis is due to: a. Tuberculosis of bone b. Pyogenic arthritis & Osteoarthritis 4d. Psoriaticarthritis 2 suppurative arthritis/pyogenic 6 months of age have the highest of complications, most of which offect the ‘hip. > The mast obvious risk factors are a delay in diagnosis ‘and treatment (more than 4 days) and concomitant cosceomyelitis ofthe proximal femur, » Subluxation and dislocation of the hip, or instability of ‘the knee should be prevented by appropriate posturing ‘or splintage. > Damage to the cartilaginous physis or the epiphysis in ‘the growing child i the most serious complication. > Sequelae include retarded growth, partial or complete destruction of the epiphysis, deformity of the joint, ‘epiphyseal osteonecrosis, acetabular dysplasia and pseudarchrosis ofthe hip. > Articular cartilage erosion (chondrolysis) is seen ‘nolder patients ond this may result in restricted ‘movement or complete ankylosis ofthe joint. > Ref: Apley’s System of Orthopedics and Fractures 9% Page no. 43-45 101. Best treatment for compartment syndrome. a. Incision and drainage b. IV antibiotics © Fasciotomy 4. Amputation of imb ‘2 Compartment syndrome > Fractures of the arm or leg can give rise to severe ‘ischaemia, even if there is no damage to @ major vessel » Bleeding, oedema or inflammation (infection) may ‘increase the pressure within one of the osseofascial ‘compartments: there is reduced capillary flow, which results in muscle ischaemia, further oedema, still greater pressure and yet more profound ischaemia ~ 0 vicious circle that ends, after 12 hours or less, in necrosis of nerve ond muscle within the compartment. Rn wr cee rer = Paraesthesia + Pallor » Paralysis é (= Pulselessmess > Treatment Bt . ~The threatened compartment (or compartments) must promptly decompressed. + The AP should be carefully monitored; fit falls below 30 _mintlg, immediate open fasciotamy ts performed. + In the case ofthe leg, asciotomy’ means opening all four ‘compartmentsthrough medial and lateral cisions. + The woundsshould be left open and inspected 2 days later: if thereis muscle necrosis, debridement can be carried out; if the tissues ore healthy, the wounds can be sutured (without cension) oF skin-grafted. 2 Ref: Apley’s System of Orthopedics and Fractures 9 edition. Page no. 713-714 102.Most com mon complication of supracondylar fracture. a. Malhunion b. Non-union Myositis ossificans 4. Volkmann's ischemic contracture ‘© Complications of supracondylar fracture » Early ‘@. Vascular injury: The great danger of supracandylar fracture is injury to the brachial artery. 1b. Nerve injury: The radial nerve, median nerve (particularly the anterior interosseous branch) ‘or theulnar nerve may be injured. » Late @ Malunion; Malunion is common. Uncorrected sideways tilt (angulation) and rotationare much |. More important and may lead to varus (orrareiy valgus) deformity of the elbow; this is permanent ‘and will not improve with growch Cubitus varus is disfiguring and cubicus valgus may cause late uinar palsy. 1b. Enbow stiffness ond myositis ossifficans 2 Ref: Apley’s System of Orthopedics and Fractures 9* edition. Page no. 760-761. 103.24 years male alleged case of RTA presented to ER with complains anterior bulge over thigh, difficulty in movements and pain. On examination Patient's leg was on flexion, abduction and externally rotated. Most likely diagnosis i a. Fracture of femur neck b. Posterior dislocation of hip © Anterior dislocation of hip 4. Acetabulum fracture > Anterior Dislocation Anterior dislocation 1s rare compared with posterior > Dislocation of one or even both hips may occur whens ‘weight falls onto the back of a miner or buildin? labourer whe 1s working with his legs wide apor. ‘kneesstruight and back bent forwards. » However, nowadaysthe usual cause 1S @ read acciden ‘air crash, » Ginical features ————E——————EEz_ Scanned with CamScannerScanned with CamScannerfso|ehat ihe busnes\end of HE SKin | a, Direct spread through skin co ent b, Hematogenous spread a Ie TecGGy er born lirt jematogenous sp! then sy mens | Lymphatic spread c 4. Direct spread from contagious focus , Various tissues ore transferred | | 2 Micro-organisms may reach the musculoskeletal with bone or muscle (osseocutaneous tissues by respectively) » Direct introductionthrough the skin (a pinprick an , : This description refers to a whole injection, a stab wound, a laceration, anopen fracture or flaps. in which tissues are isolated an operation). vessels chat run from more major | > Direct spread froma contiguous focusof infection » Indirect spreadvia the blood streamfrom a distant site such as the nose or mouth, the respiratory trac, the bowel or the genitourinary tract (most common route). 12 Ref: Apley’s System of Orthopedics and fractures 9% edition. Page no. 2: the surface. Pyogenic FFasciotomy [Uinar nerve Anter dislocation. Pedicle fap ts Anesthesia 109.Which of the following drug has no enzymatic degradation and excretion? Naind Love's Short Practice of Surgery 27" | 2. Atracurium b, Halothane no. 634-650. . Isoflurane 4. Fentanyl 107.L4-L5 disc prolapse causes compression of which | > Classifications of Neuromuscular Blocking agents 4 R cassifcatons of Neon nerve root? ‘Nondepolarizing a 13 b. L4 « LS da Si ae i * Succinylcholine Long-acting » Acute (prolapse, rupture) is much less = Pancuronium common more dramatic than chronic Intermediate-acting * Vecuronium + Physical stress (combination offlexion and compression) is = Rocuronium the proximate cause but, even at L4/5 or LS/SI (where = Atracurium: stress is mast severe) it seems unlikely that o disc would = Cisatracurium rupture ‘there was also some disturbance of the Short-acting of the nucleus. = Mivacurium mf ‘rupture moy cause compression of the ‘D Renal disease markedly alters. the pharmacokinetics! ve ‘only the long-acting nondepolarizing NMBDs, swhes pe! i pancuronivm. > A posterolateral rupture presses on the nerve root 2 ‘The intermediate-acting NMBDs areeliminated, by ‘he ‘proximal to its point of exit throughthe intervertebral liver (rocuronium), by metabolism by plasm? foramen; thus a herniation at L4/S will compress the fifth cholinesterase (mivacurium), by Hofmann elimination jumbar nerve root, and a herniation at 15/51, the first {atracurium or cisatracurium), or by a combination?! sacral root. these mechanisms + Sometimes @ loca! inflammatory response with oedema | 2 Hydrobsis of SCh to inactive metabolites = ‘oggravates the syraptoni Paes plasma cholinesters® les and Fractures 9 (pseudocholinesterase) producedin the liver. 2 Ref. Apley's System of Orthoped 2 sAtracurtum:Atracirium. is a. bisquaterm”” edition. Page no. 478-481. ‘benzylisoquinolinium nondepolarizing NMBD 02 mg/K9 108.Common mode of transmission of infection to that produces an onset of ncaa oft 5 minutes and ° bone and joints. duration of action of 20 to 35 minutes. — Scanned with CamScanner110 tindotracheal stubation ts confirmed ber + Carbon dioxide in expired aip id 1 Hy auNcultation of bilateral cheyt Abuenew of gurgling sound over oplgastalum Hulse oximetry 113, Late complication of subarachnoid block is: for infant comes 10900 How many vamenthetic/preoperative ce ven breast ane before surgery baby can be fiver Tee On b, Ahours hours: 4, Bhours 16 months Scanned with CamScannerEar, nose and throat 115.Which of the following is contraindication of tonsillectomy? 2. Peritonsillar abscess ‘b. Malignancy c. Cleft palate 4. Obstructive sleep apnea 2 Contraindications of Tonsillectomy > eve less thon 10 9% > Presence of ecue infection in upper respiratory tracteven cute tonsilitis.Bleding is more in the presence ofacte Infection. + Children under 3 years of age. They are poor surgical risks, » Qvert or submucous cleft palate. ? Bleeding disorders, eg. 1 or haemophilia. “Teecne feo Jeukaemia, purpura, > ae , disease, eg. diabetes, cardiac neon srtemic: dics > 'during the period of menses 2 Ref "Nose and Throat PL Dhingra 6 edition. no. 428. 116. Tobacco chewing causes all except? a. Squamous cell carcinoma b. Nicotine stomatitis ©. Keratosis @. Root caries 2 Effects of Tobacco on Oral cavity, Teeth, Gingiva and ‘periodontal tissue % The main categories of smokeless or chewing tobacco- ‘induced oral mucosal soft-tissue lesions reported are: oral ‘squamous cell careinoma (SCC) and verrucous carcinoma; oro! potentially malignant disorders (OPMDs) :c0 pouch lesion and lime users' lesion, oral i ‘cous fibrosis (OSF) when mixed with teeth is a common stains bind chewing. ‘enamel, dentin, root surfaces causing a brown to tack discolouration. > Among smokeless tobacco users, there is an increased ‘gingival recession with exposure of tooth root surface, ‘periodontal pocket formation, plaque and calculus ‘accumulation which leads to periodontitis. 2 Ref hetps:// www.ncbinim.nih.gov/ pmc/ articles/ ‘PMC6172921/ 117, Bulla ethmoidalis is prolongation of: Uncinate process Anterior ethmoidal air cells Frontal sinus Middle turbinate Butta ethmoidalis It is an ethmoidal cell situated behindthe uncinate process. + Anterior surface of the bulla formsthe posterior boundary of hiatus semilunaris. Depending on pneumatization, bulla may be o pneumatized cellor a solid bony prominence. > When there is a space above or behind the bulla, i is calledsuprabullar or retrobullar recesses, respectively. The suprabullar and retrobullar recesses together formthe lateral sinus (sinus lateralis of Grunwald). > The clef-like communication between the bulla andskull ‘base and opening into middle meatus is also calledhiatus ‘semilunaris superior. Ref: Disease of Ear, Nose and Throat PL. Dhingra 6% edition, Page na. 137-138. 118.After tracheostomy which of the following changes occur? a. Decrease in dead space b. Increase in subglottic pressure © Increased ventilation perfusion ratio d. Increased humidification of air > Functions of Tracheostomy 1. Alternative pathway for breathing, This circumventsany obstruction in the upper airway from lips to the ‘tracheostome. ea 2 Improves alveolar ventilation. In cases of repitoninsficen, alveolar veriation improved % Decreasing the dead space by 30-50% (normal deadspaceis 150 mL), Reducing the resistance to airflow. 3 Protects the airways, By using cuffed tube, ‘acheobronchial tree is protected agains aspiration of- -& Pharyngeal secretions, as in case of bulbar paralystsor soar coma, 'b, Blood, as in haemorrhage from pharynx, larynx oF injures, Scanned with CamScannerScanned with CamScanner1123 Patient having orbital floor fracture complains of diplopia. Which muscle is involved for diplopia? a. Lateral rectus b. Medial rectus © Superior oblique d._ Inferior rectus the orbitalfloor ‘blows out, but it can ‘medial wall ofthe orbit. {floor fractures. the eye and its surrounding may collapse into the maxillary sinus.causing ‘enophthalmes and entrapment of the inferiorrectus » The patient may present with pain, local tenderness, associated damage to the sinuses may corbitalcrepits. » infroorbial Iypoesthesia may be present because of an ‘entrapment ofthe infraorbital nerve, > terthe inflammation resolves, the patient is lft with a relative enophthalmes and restricted ocularmotlty fractures corbical the globe ma pe and be dapreaed th 2 resto ‘roublesome diplopia (traumatic enophthalmas). 2 Ref Parson's Disease of Eye 22" edition. Page no. 499-500. years old child dev painful white eye cause is 2. Congenital cataract b. Openangle glaucoma c Retinoblastoma —-d._Acuteiridocyclitis 2 Causes of white reflex in pupillary area (Leskocoria/Amaurotic cat’s eye appearance) > Congenital cataract (white eye from birth) > Retinoblastoma 1» Persistent hyperplastic primary vitreous » Retrolental fibroplasia '» Texocara endophthalmitis “Goat's disease + Retinoblastoma: Retinoblastoma iso common malignant -arisingfrom the neurosensory retina in one oF both Sule ps sudden onset of in 25-30% coses, there iit) 5. Bilaterality involvement, although one eye is affected more extensively ‘and earlier than the other. 2 Presenting features of retinoblastoma Presenting symptoms Percentage Leukocoria 60% Strabismus 20% Painful red eye 1% Poor vision 5% ‘Asymptomatic 3% Orbital cellulitis 3% Unilateral mydriasis 2% Heterochromia iridis 1% Hyphema_ 1% D Ref AK Khurana Comprehensive Ophthalmology 6 edition. Page no. 303-309. 125, Cataract in diabetic patient b. Glucose d. Sorbitol is due to; Galactose Lactic acd Diabetic cataract Diabetes is associated with two types of eataracts: 1, Senile cataract in diabetics appears at an early age and progresses rapidly. 2. True diabetic cataract. > The classical diabetic cataract is also called ‘snowfake cataract or ‘snowstorm cataract’ » Ie is.a rare condition, usually occurring im young od due to osmotic aver hydration ofthe lens. > Osmotic over hydration of the lens occurs due ‘© ‘accumulation of sorbitol, when glucose is metabolized by NADPH+ dependentaldose reductase. > Initially, @ large number of fluid vacuoles appest tnderneath the anterior and posterior capsules which ‘soon followed by appearance of bilateral snowfiake-ike white opacities in che cortex. Such opacities may resolve spontaneously or mature within a few days. 2 Ref: AK Khurana Comprehensive Ophthalmology =o edition. Page no. 193 : Answer B. BEY ring of FEA inferior — PEPE cinastoma PEER sorbic ed Dermatology 126. Treatment regimen for paucibacillary leprosy © a. Dapsone 100 mg daily and Rifampicin 600 "= monthly b. Dapsone 100 mg daily and rifampicin 600 mg dally €. Clofazimine 50 mg QID and Rifampicin 600 daily 4d. Dapsone 100 mg daily and Clofazimine SO mg Qi 2 WHO recommendation for treatment of leprosy ™ ‘adults A Scanned with CamScanner