UPSC PAPER-1 1998

1.      In ulcerative colitis, the inflammatory process is usually confined to:

A.   Mucosa alone

B.   Mucosa and submucosa

C.   Mucosa, submucosa and muscularis

D.   Mucosa, submucosa, muscularis and serosa

Ans. B  (Harrison 16th ed., p 1778)

In ulcerative colitis the inflammation is confined to mucosa and superficial submucosa usually. In fulminant disease the deeper layers are also involved.

See Q 98 of UPSC 1999 paper 1 for clinical features and treatment of ulcerative colitis.

2.      Cleft palate should be repaired at the age of:

A.   6 to 12 months                                                                         B.    12 to 18 months

C.   18 months to 4 years                                                              D.    4 to 7 years

Ans. B  (Bailey and Love 23rd ed., p 589-590; 24th ed., p 649)

According to Bailey and Love cleft palate repair is frequently performed between 6 and 18 months. Cleft lip repair is commonly done between 3 and 6 months of age.

In this question it is not mentioned whether it involves soft palate, hard palate or both. According to Bailey & Love for soft palate (only) repair is done by one operation at 6 months of age, when cleft involves both soft and hard palate then soft palate is repaired by one operation at 6 months of age and the hard palate is repaired at 12-15 months of age. However in general operation is usually done around one and half years of age. Considering all these facts the answer is choice B.

3.      Aneurysmal bone cysts:

A.   Are true aneurysms of nutrient arteries

B.   Occur only in flat bones

C.   Are the same as osseous haemangiomas

D.   Manifest as osteolytic lesions in long bones

Ans. D  (Bailey and Love 23rd ed., p 277; 24th ed., p 434)

Features of aneurysmal bone cyst:

–   A benign bone lesion, more common in long bones.

–   Aneurysmal bone cyst forms expanding osteolytic lesion containing bloody fluid.

–   Gradually increasing swelling is a common presentation. There is little pain and often presents as pathological fracture.

–   On x-ray examination there is expansion of overlying cortex, trabeculation within substance of tumor. Eccentric well defined radiolucent area.

–   Treatment consists of curettage and bone grafting.

–   Recurrence is seen in 25% of cases.

4.      Volkmann’s contracture:

A.   Is localised thickening of palmar fascia

B.   Develops at the ankle in a case of chronic venous ulcer

C.   Follows ischaemia of the forearm muscles

D.   Is due to excessive scarring of the skin of the arm following a burn

Ans. C  (Maheshwari 3rd ed., p 85)

Among the choices given in the question Volkmann’s contracture follows ischaemia of the forearm muscles commonly the flexor compartment of the forearm.

1.  Volkmann’s ischaemia also called compartment syndrome is also seen in lower limb muscles.

2.  In forearm it is caused by the occlusion of brachial artery by:

–   Supracondylar fracture of humerus.

–   Fracture both bones forearm.

–   Dislocation of elbow.

3.  Most common muscles affected are flexor pollicies longus and flexor digitorum profundus (medial half).

4.  Volkmann’s ischaemia is an orthopedic emergency.

5.      In the case of a 65-year old person, with fracture neck of femur, the treatment of choice is:

A.   Close reduction

B.   Close reduction with internal fixation

C.   Open reduction

D.   Replacement of head and neck of the femur with a prosthesis

Ans. D  (Maheshwari 3rd ed., p 116)

Fig.: Treatment plan of fresh (< 3 weeks) fracture of neck of femur.

6.      The procedure of choice in the case of a child who has inhaled a peanut is:

A.   Endotracheal suction                                                              B.    Tracheostomy

C.   Bronchoscopy                                                                          D.    Immediate thoracotomy

Ans. C  (OP Ghai 6th ed., p 367)

Bronchoscopy should by undertaken if the clinical and radiological picture suggests the diagnosis even when the history of foreign body aspiration is not forthcoming. The foreign body can be removed under direct vision by bronchoscopy.

Inhaled peanut may cause stridor and respiratory distress. If not removed early it may cause pneumonia later.

7.      While performing orchidectomy for testicular tumours, the spermatic cord is ligated:

A.   At the deep inguinal ring                                                        B.    At the superficial inguinal ring

C.   At the neck of scrotum                                                           D.    Just above the epididymis

Ans. A  (Bailey and Love 24th ed., p 1413; Harrison 15th ed., p 616)

While performing orchidectomy for testicular tumors, the spermatic cord is ligated at the deep inguinal ring.

Orchidectomy is essential to remove the primary tumour. While doing orchidectomy clamp is placed over the cord at the very beginning to stop dissemination of malignant cells. Spermatic cord is displayed by dividing the external oblique aponeurosis through groin incision.

8.      Renal trauma is best treated by:

A.   Observation and supportive measures

B.   Early drainage and perirenal haematoma

C.   Heminephrectomy

D.   Nephrostomy

Ans. A  (Bailey and Love 24th ed., p 1311)

Conservative treatment of closed renal trauma is usually successful but appropriate measures must be instituted without delay.

Surgical exploration is necessary in less than 10% of closed injuries and is indicated if either there are signs of progressive blood loss or there is an expanding mass in the loin.  Approach should be trans-peritoneal.

Remember the following important points about renal trauma:

1.  An intravenous urogram (IVU) should be obtained urgently:

a.  To assess the damage to kidney and

b.  To show that other kidney is normal.

2.  Closed renal injury is almost always extraperitoneal, exception is seen in young children who have very little extraperitoneal fat.

3.  Haematuria is cardinal sign of damaged kidney. Profuse bleeding may be accompanied by clot colic.

4.  Sudden profuse haematuria between 3rd day and 3rd week after accident is due to clot becoming dislodged.

5.  Abdominal distension 24-48 hours after renal injury is probably due to retroperitoneal haematoma implicating splanchnic nerves.

9.      A one-month old baby is brought with complaints of photophobia and watering. Clinical examination shows normal tear passages and clear but large cornea. The most likely diagnosis is:

A.   Congenital dacryocystitis                                                      B.    Interstitial keratitis

C.   Keratoconus                                                                             D.    Buphthalmos

Ans. D  (Parsons’ Diseases of the Eye 19th ed., p 214)

Buphthalmos is also called hydrophthalmos or infantile glaucoma. The symptoms are photophobia and defective vision. The eyeball enlarges and becomes enlogated and oval. Edema and enlarge­ment of cornea occurs. Intraocular tension is raised and cupping of optic disc occurs. Treatment is not very satisfactory but trabeculotomy, goniotomy etc are done with varying results.

Keratoconus also called conical cornea is due to congenital weakness of the cornea. The cornea is thin in the centre and progressively bulges forwards. The apex of the cone always being sightly below the centre of the cornea. The condition is almost invariably bilateral.

10.    A 10-year old boy presents with nasal obstruction and intermittent profuse epistaxis. He has a firm pinkish mass in the nasopharynx. All of the following investigations are indicated in this case except:

A.   X-ray base of skull                                                                  B.    Carotid angiography

C.   CT scan                                                                                     D.    Biopsy

Ans. D  (Logan Turner 10th ed., p 111; Bailey and Love 23rd ed., p 677-678)

The child is suffering from nasopharyngeal angiofibroma.

Nasopharyngeal angiofibroma is found commonly in adolescent boys. It is an invasive tumour which does not  involve bones but expands. Involvement of periosteum of base of skull can occur. A less vascular variety can be confused with antrochoanal polyps. Tumour tends to regress after 25 years of age. Surgery is the mode of treatment for nasopharyngeal angiofibroma. Surgery is done by transpalatine approach or Danker’s approach. Tumour has to be removed completely otherwise severe bleeding may occur.

The age group and clinical picture are the clues for the diagnosis of angiofibroma. Biopsy from the mass will confirm the diagnosis. However according to Bailey and Love biopsy should be avoided as it leads to severe bleeding. Angiography helps us to study the blood supply to angiofibroma. X-ray base of skull and CT scan will help in detecting the extent of the mass.

11.    Carcinoma of the true vocal cord at an early stage is best treated by:

A.   Excision of the growth through laryngofissure                  B.    Radiotherapy

C.   Total laryngectomy                                                                D.    Chemotherapy

Ans. B  (Logan Turner 10th ed., p 176)

Tumours limited to cords can be treated by surgery or radiotherapy with equal chances of cure. But radiotherapy is the treatment of choice as laryngeal functions are preserved.

When cancer is localized to vocal folds there is more than 90% 5 year disease free cure rate when treated with radiotherapy alone.

Remember the following important points commonly asked in examination:

1.  Glottis is the commonest site of laryngeal cancer.

2.  Cancer is confined to vocal cord for a long time because of lack of lymphatics and metastasis.

3.  Cancer of larynx is the commonest head and neck cancer.

12.    Consider the following statements:

         ‘Unsafe’ chronic suppurative otitis media is:

1.   Central perforation of the tympanic membrane

2.   Posterior perforation of the tympanic membrane

3.   Usually dry

4.   Associated with accumulation of skin debris with purulent and offensive discharge

         Of these statements:

A.   1 and 3 are correct                                                                  B.    2 and 3 are correct

C.   1 and 4 are correct                                                                  D.    2 and 4 are correct

Ans. D  (Dhingra 3rd ed., p 89)   

In unsafe CSOM posterosuperior part (attic, antrum and mastoid) of tympanic membrane is involved and there is attic or marginal perforation. It is associated with accumulation of skin debris with purulent and offensive discharge i.e., cholesteatoma formation.

Cholesteatoma causes erosion of the bone. It involves attic, antrum and the posterior tympanum. It is also considered the dangerous or the unsafe variety of CSOM.

Cholesteatoma can only be eradicated from the temporal bone by surgical resection. The main purpose of surgery is eradication of disease with management of complications and reconstruction of middle ear. Several factors are taken into considerations for example:

a.  Nature and extent of disease.

b.  Presence of complications.

c.  Hearing state of both the ears.

d.  Eustachian tube functions.

e.  Mastoid pneumatization.

f.   General medical condition.

g.  Skill of surgeon etc.

l   Surgery of choice in cholesteatoma is modified radical mastoidectomy.

Table: Differences between atticoantral and tubotympanic type of CSOM.

                                         Tubotympanic or safe type                              Atticoantral or unsafe type

Discharge                       Profuse, mucoid, odourless                              Scanty, purulent, foul smelling

Perforation                     Central                                                                   Attic or marginal

Granulations                  Uncommon                                                          Common

Polyp                               Pale                                                                        Red and fleshy

Cholesteatoma             Absent                                                                   Present

Complications               Rare                                                                       Common

Audiogram                     Mild to moderate conductive deafness           Conductive or mixed deafness 

13.    Claw hand deformity is the characteristic of a lesion of:

A    Median nerve                                                                           B.    Musculocutaneous nerve

C.   Radial nerve                                                                             D.    Ulnar nerve

Ans. D  (Maheshwari 3rd ed., p 51)

Claw hand (Main-en-graffe) means hyperextension at the metacarpo-phalangeal joints and flexion at the proximal and distal interphalangeal joints. This occurs due to paralysis of the lumbricals, which flex the metacarpo-phalangeal joints and extend the interphalangeal joint (intrinsic minus hand).

Clawing is more marked in low ulnar nerve palsy than in high ulnar nerve palsy because in the latter flexors of the fingers are also paralysed.

In ulnar nerve palsy, only the medial two fingers develop clawing while all the four fingers develop clawing in combined median and ulnar nerve palsies.

Clawing may not become apparent in early post injury period.

Remember some other characteristic frequently asked deformities:

–   Wrist drop: Radial nerve palsy.

–   Foot drop: Common peroneal nerve palsy.

–   Winging of scapula: Paralysis of serratus anterior in long thoracic nerve palsy.

–   Ape/simian thumb deformity: Median nerve palsy.

–   Pointing index: Due to paralysis of flexor digitorum superficialis and that of lateral half of the flexor digitorum profundus muscle in median nerve palsy.

–   Policeman tip deformity: Erb’s palsy due to involvement of C5 and C6.

–   Other tests of ulnar nerve: Egawa test, Card test, Froment sign /book test.

–   Causes of complete claw hand are combined ulnar and median nerve palsy, VIC, leprosy, poliomyelitis, syringomyelia, amyotrophic lateral sclerosis, progressive muscular atrophy.

14.    In a patient with head injury, black eye associated with subconjunctival haemorrhage occurs when there is:

A.   Fracture of floor of anterior cranial fossa

B.   Bleeding between the skin and galea aponeurotica

C.   Haemorrhage between galea aponeurotica and peri-cranium

D.   Fracture of greater wing of sphenoid bone

Ans. A  (Bailey and Love 23rd ed., p 549; 24th ed., p 595)

Anterior fossa fractures present with subconjunctival haematomas, anosmia, epistaxis and CSF rhinorrhoea and may occasionally be associated with caroticocavernous fistulae.

Periorbital or Racoon eyes indicate subgaleal haemorrhage and not necessarily base of skull fracture as do subconjuntival haemorrhages extending beyond the conjunctival reflections.

Both black eyes with subconjunctival haemorrhage are seen in fracture of anterior cranial fossa

l   Battle sign: Bruising behind the ear occurring 36 hours after a head injury with petrous temporal base of skull fracture.

15.    All of the following are true of arterial blood gas analysis except:

A.   Plastic syringe should be used

B.   Syringe should be flushed with heparin and emptied completely

C.   Syringe should be sealed with cork or a cap

D.   Samples should be preserved in a cool environment

Ans. B  (Kumar and Clark 4th ed., p 850)

For ABG analysis syringe should not be emptied completely. After flushing with heparin, excess heparin should be expelled except that filling the dead space of the syringe and needle. After drawing 2-4 ml of blood from a peripheral artery (radial, femoral) air bubble should be removed and after this the tip of the needle should be inserted in a cork.

For ABG analysis samples should not be preserved; rather it should be analyzed as early as possible. It can be kept in room temperature for a maximum of 10-15 minutes that too if it cannot be analyzed immediately. If immediate analysis is not possible then the syringe should be kept in cool environment. If kept in room temperature then with every 10 minutes pH drops by 0.01, PO2 falls by 0.1 mmHg and PCO2 increases by 0.1 mmHg. The sample should be discarded if it is not analyzed within 2 hours of keeping it in cool environment.

16.    The anaesthetic drug that is contraindicated in the presence of jaundice is:

A.   Halothane                                                                                 B.    Ether

C.   Gallamine                                                                                 D.    Nitrous oxide

Ans. A  (Short Textbook of Anaesthesia 2nd ed., Ajay Yadav p 61, 138)

In patients with abnormal liver functions halothane should not be used. It can cause halothane hepatitis. Inhalational agent of choice in such patients is isoflurane. Anaesthesia is maintained on oxygen (50%), nitrous oxide (50%), isoflurane and atracurium. Risk factors for halothane hepatitis are multiple exposures (single most important factor), hypoxia, middle age, obesity, females, patients with other autoimmune diseases. Pathologic lesion is centrilobular necrosis. Hepatotoxicity may occur due to toxic reaction to a metabolite or due to hypersensitivity reaction. Genetic factors may also be of importance. In children halothane can be given repeatedly but in adults particularly obese, middle aged women at intervals less than 12 weeks may cause acute liver damage. Severe liver damage is unlikely to occur following single administration of halothane.

17.    In the commonest form of oesophageal atresia:

A.   The lower pouch opens into the trachea

B.   The upper pouch opens into the trachea

C.   Both lower and the upper pouch open into the treachea

D.   Both lower and the upper pouch have a blind ending

Ans. A  (OP Ghai 6th ed., p 178)

In the most common type of tracheo-oesophageal fistula the upper part of oesophagus ends blindly and the lower part of oesophagus is connected to trachea with a fistula. In this type of esophageal atresia the infant has drooling of saliva and with the first feed there is overflow of milk and saliva.

Fig.: Commonest type of tracheo-oosophageal fistula.

18.    Which one of the following operations is carried out for the treatment of congenital hypertrophic pyloric stenosis?

A.   Pyloromyotomy                                                                      B.    Pylorectomy

C.   Pyloroplasty                                                                             D.    Gastrojejunostomy

Ans. A  (Bailey and Love 24th ed., p 1033)

Ramstedt’s pyloromyotomy is done in congenital hypertrophic pyloric stenosis. In this operation the hypertrophied muscles are incised and the stenosis is relieved.

Congenital hypertrophic pyloric stenosis is most common surgical cause of vomiting in infants.

It affects first born males more commonly (4:1) and incidence is 3 per 1000 live births. Most commonly seen at 4 to 6 weeks after birth. Non bilious vomiting is the presenting symptom which becomes forcible and projectile after 2-3 days. Immediately after vomiting child is usually hungry. By 2 to 4 weeks complete obstruction develops. Weight loss is a striking feature and rapidly the infant becomes emaciated and dehydrated. Infant develops hypokalemic, hypochloremic metabolic alkalosis with paradoxical aciduria. Diagnosis can usually be made with a test feed. This produces characteristic peristaltic waves that can be seen to pass across the upper abdomen. At the same time, using a warm hand, the abdomen is palpated to detect the lump in the right upper quadrant (typical ‘olive’ felt). Ultrasonography is investigation of choice (95% diagnostic accuracy). Treatment is surgical (Ramstedt’s operation).

19.    Dentigenous cyst arises from:

A.   The root of a caries tooth

B.   The periosteum of the fractured mandible

C.   An unerupted permanent tooth

D.   The sequestrum of osteomyelitis of mandible

Ans. C  (Bailey and Love 23rd ed., p 597)

Dentigerous cyst arise as a result of separation of the reduced enamel epithelium from the surface of the crown of an unerupted tooth with accumulation of fluid. The tooth is displaced deeper into the jaw and is prevented from erupting by the cyst. Cyst lining is usually attached around neck of tooth so that crown, prortudes into the cyst cavity. On the contrary, the dental cysts develop at the apices of teeth with necrotic pulps.

20.    Match List-I with List-II and select the correct answer using the codes given below the Lists:

         List-I                                                                                                    List-II

a.   Pancreatic tumour                                                                        1.   Beckwith syndrome

b.   Wilms’ tumour                                                                              2.   Multiple endocrine neoplasia II

c.    Parathyroid adenoma                                                                        3.   Multiple endocrine neoplasia I

d.   Medullary carcinoma thyroid                                                           4.   Zollinger Ellison syndrome

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       4     1     2     3                    4     1     3     2                  1      4       2      3                    1      4    3    2

Ans. B 

Table: Multiple endocrine neoplasia.

MEN 1                                                                                                                MEN 2

                                                                            MEN 2A                                                  MEN 2B

Parathyroid hyperplasia or adenoma             Pheochromocytoma                             Medullary thyroid CA

Pituitary hyperplasia or adenoma                   Medullary thyroid CA                            Pheochromocytoma

Islet cell hyperplasia, adenoma or carcinoma                                                               Parathyroid hyperplasia or adenoma     Mucosal and gastrointestinal neuromas

Less commonly                                                  Cutaneous lichen                                  Marfanoid features

Foregut carcinoid, pheochromocytoma,        Amyloidosis

subcutaneous or visceral lipomas, dermal     Hirschsprung disease

angiofibromas or collagenomas

See Q 92 UPSC 2000 paper 1 for role of gastrinoma in ZES.

The features of Beckwith-Wiedman syndrome are hemihypertrophy, macrosomia, macroglossia, omphalocele and increased risk of Wilm’s tumour.

21.    Match List-I with List-II and select the correct answer using the codes given below the Lists:

      List-I                                                                                               List-II

a.   Grahm’s patch with closure of perforation                              1.   Periampullary carcinoma

b.   Lord’s operation                               2.                                         Varicose veins

c.   Whipple’s operation                         3.                                         Vaginal hydrocele

d.   Trendelberg operation                      4.                                         Duodenal ulcer perforation

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       3     4     1     2                    3     4     2     1                  4      3       2      1                    4      3    1    2

Ans. D  (Bailey and Love 24th ed., p 963, 1058, 1130, 1408)

Disease                                                                  Operation

Vaginal hydrocele                                                Lord operation

                                                                                 Jabouley’s procedure

Periampullary carcinoma                                   Whipple operation (pancreaticoduodenectomy)

Varicose veins                                                       Trendelenberg operation (saphenofemoral ligation)

Duodenal ulcer perforation                                Grahm’s patch with closure of perforation

                                                                                 Billroth type II gastrectomy

In patients with massive duodenal or gastric perforation simple closure is impossible.

22.    Laparoscopic cholecystectomy is best avoided in patients with:

A.   Hypertension

B.   Diabetes

C.   Obesity

D.   COPD (chronic obstructive pulmonary disease)

Ans. D  (Bailey and Love 23rd ed., p 1298)

Severe chronic obstructive airway disease and ischaemic heart disease may be contraindications to the laparoscopic cholecystectomy.

–   Moderate obesity does not increase operative difficulty significantly.

         The following 8 (eight) items consist of two statements, one labelled the ‘Assertion A’ and the other labelled the ‘Reason R’. You are to examine these two statements carefully and decide if the Assertion A and the Reason R are individually true and if so, whether the Reason is a correct explanation of the Assertion. Select your answers to these items using the codes given below and mark you answer sheet accordingly:

Codes:

A.   Both A and R are true and R is the correct explanation of A

B.   Both A and R are true but R is not a correct explanation of A

C.   A is true but R is false

D.   A is false but R is true

23.    Assertion A         :   Acute retropharyngeal abscess is on one side of the midline.

         Reason R             :   Retropharyngeal space is divided into two compartments by a strong midline fascial septum.

Ans. A  (Dhingra 3rd ed., p 320-321)

In acute retropharyngeal abscess bulge is seen in posterior pharyngeal wall usually on one side of the midline.

Retropharyngeal space lies behind pharynx between the buccopharyngeal fascia covering pharyngeal constrictor muscles and the prevertebral fascia. The space is divided into two lateral compartments (spaces of Gillette) by a fibrous raphe. Parapharyngeal space communicates with the retropharyngeal space.

Causes of acute retropharyngeal abscess:

–   In children: Suppuration of retropharyngeal lymph nodes secondary to infection in adenoids, nasopharynx, posterior nasal sinuses or nasal cavity.

–   In adults: Penetrating injury of posterior pharyngeal wall or cervical oesophagus.

Rarely pus from acute mastoiditis tracks along the undersurface of petrous bone.

Clinical features:

Dysphagia, difficulty in breathing, stridor, cough, torticollis and bulge in posterior pharyngeal wall.

On X-ray soft tissues lateral view of neck, widening of prevertebral shadow and possibly even presence of gas may be seen.

Incision and drainage is done usually without anaesthesia. Incision is given in the most fluctuant area of the abscess.

Chronic retropharyngeal abscess:

Tubercular in nature.

Causes:

–   Caries of cervical spine.

–   Tuberculous infection of retropharyngeal lymph nodes secondary to tuberculosis of deep cervical nodes.

Clinical features: Discomfort in throat. Dysphagia is not marked.  Posterior pharyngeal wall shows a fluctuant swelling centrally or on one side of midline.

Treatment: Incision and drainage and full course of ATT.

24.    Assertion A         :   Left lobe liver abscess is treated by laparotomy and external drainage.

         Reason R             :   It often ruptures into left pleural cavity.

Ans. C  (Harrison 16th ed., p 1216)

Left lobe of liver abscess is aspirated to prevent rupture into pericardium and cardiac tamponade.

The other indications of aspiration of liver abscess are:

1.  To rule out pyogenic abscess in multiple liver abscesses.

2.  Failure to respond to therapy.

3.  Imminent rupture.

25.    Assertion A         :   Patients with posterior flail segment following chest injury do not need assisted ventilation.

         Reason R             :   Posterior flail chest does not cause respiratory embarrassment.

Ans. B  (Schwartz Principles of Surgery 6th ed., p 679)

Patients with posterior flail segment after chest injury do not require assisted ventilation because of strong muscular and scapular support and because of patient’s natural tendency to lie with their back against the mattress. However this is true only when there is no major intrathoracic damage.

26.    Assertion A         :   20% mannitol solution given intravenously in a case of head injury reduces oedema and swelling of brain.

         Reason R             :   Mannitol increases plasma osmolality thus drawing fluid from extravascular compartment into the blood.

Ans. A  (Harrison 16th ed., p 1631, 2450)

The question is self-explanatory. Mannitol is one of the most frequently used drug for reduction of brain oedema and raised ICT after head injury. Steroid, furosemide, hyperventilation are the other methods used for reducing ICT.

27.    Assertion A         :   For acute fissure in ano, lateral sphincterotomy is best carried out under intravenous ketamine anaesthesia.

         Reason R             :   Ketamine provides satisfactory analgesia.

Ans. D  (Bailey and Love 24th ed., p 1254; Short Textbook of Anaesthesia 2nd ed., Ajay Yadav p 77-78)

Because of severe pain associated with anal fissure the object of all treatment is to obtain complete relaxation of the internal sphincter. Provided all the complications are dealt with, the fissure will slowly heal as soon as all spasm has disappeared.

Treatment is conservative initially, consisting of laxatives and chemical agents in the form of ointments e.g., glyceryl trinitrate designed to relax the anal sphincter and improve blood flow.

Surgery is indicated if the above measures fail and consists of lateral internal sphincterotomy or anal advancement flap. Lateral internal sphincterotomy consists of division of internal sphincter away from the fissure itself. Healing is usually complete within 3 weeks. For surgery GA is best, but can be done under LA in the form of xylocaine or lignocaine introduced into ischiorectal fossa on each side or under caudal anaesthesia.

Ketamine is a phencyclidine derivative and is used as an intravenous anaesthetic. Its solution pH is acidic (3.5-5.5) and is highly lipid soluble.

It is a strong analgesic. Onset of action is within 30-60 seconds. Early regain of consciousness after 15-20 minutes is because of redistribution. Elimination half-life is 2-3 hours. It is metabolised in liver and metabolites are excreted in urine. It is not a muscle relaxant (rather it increases muscle tone).

Its primary site of action is thalamocortical projection. It produces dissociative anaesthesia. Emergence reaction is seen in 10-30%. Hallucinations are the most common side effect of ketamine. It raises intracranial tension.

It stimulates sympathetic system causing tachycardia and hypertension and so it is IV anaesthetic of choice for shock. It is a potent bronchodilator. So it is IV anaesthetic of choice for asthmatics. It increases intraocular tension.

IV dose is 2 mg/kg and IM dose is 5-10 mg/kg. It can be used as sole agent for minor procedures (like incision and drainage), burn dressings.

28.    Assertion A         :   In a child with diagnosis of ileal atresia, barium enema study is desirable.

         Reason R             :   Ileal atresia is associated with microcolon.

Ans. D  (Bailey and Love 23rd ed., p 1071; 24th ed., p 1431; Schwartz Principles of Surgery 6th ed., p 1134; West Afr J Med 2004 Apr-Jun; 23(2):186)

Barium studies are avoided in intestinal atresia due to chances of perforation and peritonitis. 

–   Diagnosis by plain radiographs is only diagnostic when air-fluid levels are seen.

–   Type 3 of ileum/jejunal atresia are associated with multiple stenosis.

Microcolon is a rare congenital cause of intestinal obstruction. It generally results from intrauterine underutilization of colon, which would include conditions in which intestinal contents are not passed into the colon during gestation. It is seen with ileal atresia. It is not seen in duodenal atresia as the middle and distal small bowel continue to shed epithelial tissue (meconium precursor) into the colon during gestation. Microcolon is also a part of megacystis-microcolon-intestinal hypoperistalsis syndrome.

Congenital atresia and stenosis are the commonest cause of acute intestinal obstruction of the newborn.

–   Most common atresia of intestine is of duodenum (35%).

–   Most common atresia of alimentary canal is of oesophagus (TOF).

–   High incidence of multiple sites atresia are seen except in case of duodenal atresia which are frequently associated with abnormalities of the heart and great vessels.

–   In duodenal atresia, double bubble appearance is seen.

29.    Assertion A         :   Vaccination against influenza is not recommended in patients with HIV infection.

         Reason R             :   The immune response to vaccination is impaired in patients with AIDS.

Ans. D  (Harrison 16th ed., p 1107)

In HIV infected patients there are no increase in the adverse reaction from live or inactivated vaccines.

However, immune response may not be as vigorous as in those with a normal immune response. Immunization is recommended when CD4+ T cell count is greater than 200/µL. In more advanced disease the role of vaccination is not very clear.

There is no contraindication of vaccination against influenza. Although live vaccine can be given against influenza but killed/inactivated vaccine is preferred.

–   Live MMR vaccine can be administered to HIV infected individuals but OPV should be avoided.

–   Inactivated polio vaccine should be used when vaccination against polio is required.

–   Live attenuated vaccines are normally contraindicated in immunocompromised patients including those with congenital immunodeficiency syndromes and those receiving immunosuppressive therapy.

30.    Assertion A         :   Patients with cirrhosis of liver and ascites are susceptible to spontaneous bacterial peritonitis.

         Reason R             :   Hypoalbuminaemia impairs the antibody mediated defence against infection.

Ans. A  (Harrison 15th ed., p 1763)

The assertion is correct. SBP occurs in patients with ascites and cirrhosis without an obvious primary source of infection.

The reason seems to be correct as well. According to Harrison “.…The ascitic fluid in these patients typically has especially low concentration of albumin and other so called opsonic proteins, which normally may provide some protection against bacteria. Although key steps in the pathogenesis of SBP remain to be elucidated, it is clear that most bacteria contributing to SBP derive from the bowel and eventually are spread to ascitic fluid by the haemotogenous route after transmigration through the bowel wall and transversing the lymphatics.…”

After going through this statement we have come to the answer as choice A. See also Q 97 paper I UPSC 1999 for explanation and details of SBP.

31.    Which of the following are associated with late systolic murmur?

1.   Rheumatic mitral regurgitation                                             2.     Mitral valve prolapse

3.   Hypertrophic cardiomyopathy                                             4.     Persistent ductus arteriosus

         Select the correct answer using the codes given below:

Codes:

A.   2 and 4                                                                                      B.    2 and 3

C.   1, 2 and 3                                                                                  D.    1, 3 and 4

Ans. B (Harrison 16th ed., p 1310)

Late systolic murmur is heard after midsystolic click in MVP due to late systolic mitral regurgitation. In MVP the mitral valve leaflets prolapse in left atrium.

In HOCM late systolic murmur may be heard because in early systole there is no impairment of ejection. However typically the murmur is midsystolic.

In rheumatic mitral regurgitation the murmur has blowing character and is pansystolic.

In PDA the murmur is continuous. It is also called machinery murmur (Gibson’s murmur).

Remember the following important points commonly asked in examination:

       Type of murmur             Cause

1.   Holosystolic                     MR, TR, VSD.

2.   Midsystolic                       AS, PS, functional murmur, MR & TR with papillary muscle dysfunction.

3.   Early systolic                   Large VSD with pulmonary hypertension, very small muscular VSD, TR in absence of pulmonary hypertension, infective endocarditis (IV drug addicts), acute MR.

4.   Late systolic                    MVPS, papillary muscle dysfunction due to infarction or ischemia.

5.   Early diastolic                 AR, PR.

6.   Middiastolic                     MS, TS.

                                                 MR, PDA or VSD: Across mitral valve.

                                                 TR and ASD: Across the tricuspid valve.

                                                 Acute rheumatic fever (Carey Coombs murmur).

                                                 Austin Flint murmur (often presystolic).

                                                 Atrial myxoma.

7.   Presystolic                       Austin Flint murmur, atrial myxoma.

8.   Continuous                      PDA, AV fistula, coronary AV fistula, anomalous origin of left coronary artery from pulmonary artery, coarctation of aorta, pulmonary embolism, communication between sinus of Valsalva and the right side of heart, mammary souffle, cervical venous hum.

32.    Which one of the following is not associated with Prinzmetal’s angina?

A.   S-T segment depression in ECG                                            B.    Migraine

C.   Raynaud’s phenomenon                                                       D.    Early morning attacks

Ans. A  (Harrison 16th ed., p 1448; Beside Interpretation of ECG – A Practical Approach 1st ed., TK Koley p 71)

Prinzmetal’s angina is variant angina. It mainly occurs at rest. It is due to coronary vasospasm. Most often the spasm occurs around an atherosclerotic plaque.

ECG shows ST segment elevation in Prinzmetal’s angina. Q waves are usually absent.

Remember: Treatment is with nifedipine. Beta-blockers are contraindicated.

33.    Consider the following statements:

         In mitral stenosis:

1.   Angina may occur

2.   Severity of stenosis is determined by closeness of opening snap and second heart sound

3.   Hoarseness of voice may be a feature

4.   Onset of atrial fibrillation is associated with fall in cardiac output

         Of these statements:

A.   2 and 3 are correct                                                                  B.    1, 3 and 4 are correct

C.   1, 2 and 4 are correct                                                              D.    1, 2, 3 and 4 are correct

Ans. D  (Harrison 15th ed., p 1344; 16th ed., p 1391-1392)

In MS angina may occur due to myocardial ischaemia secondary to coronary atherosclerosis. Chest pain also may be due to pulmonary hypertension.

See Q 86 paper 1 UPSC 1999 for details of opening snap. Hoarseness of voice may be due to stretching of left recurrent laryngeal nerve due to enlargement of left atrium.

Atrial fibrillation decreases cardiac output by causing high ventricular rate and inadequate LV filling.

34.    All of the following are features of malignant hypertension, except:

A.   Grade IV hypertensive retinopathy                                     B.    Haemolytic blood picture

C.   Renal failure                                                                             D.    Respiratory failure

Ans. D  (Harrison 16th ed., p 1480)

Respiratory failure is not a feature of malignant hypertension. Fundus examination reveals papilloedema with haemorrhage and exudates.

It may present as hypertensive encephalopathy in the form of headache, vomiting, altered sensorium.

It may present as CCF.

Oliguria with azotaemia is the renal manifestation of malignant hypertension. Fibrinoid necrosis of walls of small renal arteries and arterioles may be seen.

Microangiopathic haemolytic anaemia is probably secondary to kidney involvement.

Nifedipine (5 mg) is given sublingually to reduce blood pressure urgently. The main problem with nifedipine is that the fall in BP can not be controlled. Sodium nitroprusside is the drug of choice for hypertensive emergency.

The following drugs have immediate effect (onset within 5 min) in treatment of malignant hypertension:

a.  Nitroprusside (0.25 µg/kg/min.): IV infusion.

b.  Nitroglycerin (5 µg/min.): IV infusion.

c.  Diazoxide (50 mg q 5 to 10 min.): IV bolus.

d.  Fenoldopam (0.1 to 0.3 µg/kg/min): IV infusion.

e.  Esmolol (250 to 500 µg/min × 1 min, then 50 to 100 µg/kg/min × 4 min): IV infusion.

The following drugs have delayed onset (within 10 to 20 min) in treatment of malignant hypertension:

a.  Enalapril (1.25 mg q 6h) : IV.

b.  Nicardipine (5 to 15 mg/h) : IV.

c.  Hydralazine (5 to 10 mg q 20 min × 3) : IV, IM.

d.  Labetalol (20 to 80 mg q 10 min) : IV.

35.    The most specific differentiating feature of ventricular tachycardia from superventricular tachycardia with aberrant conduction is:

A.   Concordant QRS pattern in all precordial leads                B.    Fixed R-R interval

C.   Fusion beats                                                                             D.    QRS duration of more than 140 msec

Ans. C  (Schamroth 7th ed., p 420; Bedside Interpretation of ECG – A Practical Approach 1st ed., TK Koley p 113)

One of the best signs of ectopic ventricular origin of a complex is ventricular fusion complex. This beat results from concomitant activation of the ventricles by supraventricular (sinus) impulse and a ventricular ectopic complex.

Presence of fusion beat indicates ventricular tachycardia.

Concordant pattern and QRS duration more than 140 msec also indicate VT.

36.    The first heart sound is loud in which of the following conditions?

1.   Mitral regurgitation                                                                 2.     Pregnancy

3.   Anaemia                                                                                   4.     Mitral stenosis

         Select the correct answer using the codes given below:

Codes:

A.   1 and 4                                                                                      B.    1, 2 and 4

C.   3 and 4                                                                                      D.    2, 3 and 4

Ans. D  (Harrison 16th ed., p 1307)

S1 is loud if diastole is short because of tachycardia (anaemia), if AV flow is increased because of high cardiac output (anaemia and pregnancy) or prolonged because of MS or if the atrial contraction precedes the ventricular contraction by unusually short interval (short PR interval).

In mitral regurgitation S1 is soft.

Remember the following important points commonly asked in examination:

1.  Commonest cause of wide split of S1 (M1T1) is complete RBBB.

2.  Reversed split of S1 (T1M1) occurs in severe MS, LBBB and left atrial myxoma.

3.  Wide split of S2 (A2 P2) is seen in:

–   RBBB: LV pacemaker.

–   LV ectopic beat: Pulmonary embolism.

–   Pulmonary stenosis: ASD.

4.  Wide and fixed split of S2 (A2P2) is seen in ASD and it occurs due to increased hangout interval.

5.  Reverse (paradoxic) split of S2 (P2A2) is seen in LBBB (commonest cause), RV ectopic beat, severe AS, large aorta to pulmonary shunt, systemic hypertension, IHD, cardiomyopathy.

6.  S3 is normal below 40 years of age. It is seen in MR and impairment of ventricular function.

7.  S4 is seen in systemic hypertension, AS, HOCM, IHD, acute MR etc. It is absent in AF.

37.    In a patient of ventricular tachycardia, the normal sinus rhythm has been restored by cardioversion. Which of the following drugs can be used to prevent further attacks of ventricular tachycardia?

1.   Mexiletine                                                                                 2.     Amiodarone

3.   Disopyramide                                                                           4.     Verapamil

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 4                                                                                  B.    2 and 3

C.   1, 2 and 3                                                                                  D.    1, 3 and 4

Ans. C  (Harrison 16th ed., p 1352-1353)

DC cardioversion is the best treatment of VT. In acute stage the preferred drug is procainamide. IV lignocaine is also very effective.

In this question all the given drugs are effective in prophylaxis of VT. We are not very sure whether the question is right or wrong. Because verapamil, class IA, IC or III agents and amiodarone are effective in management of VT. Mexiletine is also effective. Beta blockers are also very helpful. However the drug is selected by programmed stimulation so that the most effective drug to prevent VT is given.

38.    Consider the following drugs:

1.   Beclomethasone                                                                      2.     Ipratropium bromide

3.   Salbutamol                                                                               4.     Nedocromil sodium

         Those which are useful in reducing bronchial airway inflammation in asthma would include:

A.   1 and 2                                                                                      B.    2 and 3

C.   3 and 4                                                                                      D.    1 and 4

Ans. D  (Harrison 16th ed., p 1514)

Glucocorticoids are not bronchodilators. It can be given by inhalation, oral or injectable route. The main effect is suppression of airway inflammation. Inhalation route is preferred to avoid systemic toxicity.

Nedocromil sodium is mast cell stabilizer. It prevents release of chemical mediators of anaphylaxis. It is not a bronchodilator. It improves lung function, reduces airway reactivity.

Salbutamol (b stimulant) and ipratropium (anticholinergic) are mainly bronchodilators.

39.    The following results were obtained on arterial blood gas analysis in a 58-year old male (while breathing room air), hospitalised on account of increasing breathlessness: pCO2 = 76 mmHg; pO2 = 32 mmHg, pH = 7.34.

         The most likely diagnosis is:

A.   Bronchial asthma                                                                    B.    Interstitial lung disease

C.   Chronic obstructive airway disease                                     D.    Left ventricular failure

Ans. C 

Patient is suffering from type II respiratory failure with respiratory acidosis.

PaO2 < 60 mmHg, PaCO2 > 50 mmHg is present in respiratory failure.

Type 1 failure has PaO2 low with normal or low PaCO2.

Type 2 failure has PaCO2 raised with low PaO2.

Bronchial asthma usually produces acute type 1 respiratory failure.

ILD produces chronic type 1 respiratory failure.

LVF produces acute type 1 respiratory failure.

COPD produces chronic type 2 respiratory failure.

Since the age is 58 years the most likely diagnosis is COPD. Bronchial asthma can also cause type 2 respiratory failure but there is no history of recurrent attacks and the patient is not young.

40.    A middle-aged patient presents with a short history of high fever and rigors. On examination, the pulse rate is 140/min and there are signs of toxaemia. Chest examination shows restriction of movement over left infraclavicular region and there is dullness on percussion. Vocal resonance is increased with low-pitched bronchial breath sound over the above area. The most likely diagnosis is:

A.   Bronchial carcinoma                                                              B.    Lung abscess

C.   Lobar pneumonia                                                                   D.    Pleural effusion

Ans. C  (Harrison 16th ed., p 11532)

The patient is suffering from lobar pneumonia. The history and examination findings are typical of pneumonia. See Q 94 paper 1 UPSC 1999 for further details.

41.    Obstructive sleep apnoea may result in all of the following except:

A.   Systemic hypertension

B.   Pulmonary hypertension

C.   Cardiac arrhythmia

D.   Duodenal ulcer

Ans. D  (Harrison 16th ed., p 1574)

Sleep apnoea is defined as intermittent stoppage of airflow at nose and mouth during sleep. It is divided into two types central and obstructive.

In central sleep apnoea respiratory drive is transiently stopped whereas in obstructive sleep apnoea respiratory drive is present but airflow is stopped due to oropharyngeal obstruction.

50% of patients suffering from obstructive sleep apnoea suffer from hypertension and 20% suffer from pulmonary hypertension. The main complaint of these patients is excessive daytime sleepiness. Bradycardia or dangerous tachyarrhythmias have been noted in some patients. Duodenal ulcer is not seen in sleep apnoea.

42.    Consider the following statements:

         Prolonged hyperventilation may lead to:

1.   Paraesthesia                                                                             2.     Low bicarbonate level

3.   Tetany                                                                                       4.     Ketonuria

         Of these statements:

A.   1, 2 and 4 are correct                                                              B.    2 and 3 are correct

C.   1, 2 and 3 are correct                                                              D.    1, 3 and 4 are correct

Ans. C  (Harrison 16th ed., p 1572-1573)

Hyperventilation is associated with increased respiratory drive, muscle effort and minute volume of ventilation. It leads to respiratory alkalosis and to counter it the bicarbonate level goes down. Alkalosis leads to dizziness, visual impairment, syncope, seizure, paraesthesia, tetany (due to decreased free serum calcium), carpopedal spasm, muscle weakness etc. Cardiac arrhythmia, periodic breathing and central sleep apnoea may be seen. Ketonuria is absent.

43.    Consider the following viruses:

1.   Hepatitis A                                                                                2.     Hepatitis C

3.   Hepatitis D                                                                                4.     Hepatitis E

         Those which spread infection by the faeco-oral route would include:

A.   1 and 4                                                                                      B.    2 and 4

C.   1 and 3                                                                                      D.    1 and 2

Ans. A  (Harrison 16th ed., p 1829)

Hepatitis E has epidemiologic features resembling those of hepatitis A which is transmitted by feco-oral route. HCV, HBV, and delta virus are transmitted through blood transfusion or by sexual contact. Hepatitis E virus is non-enveloped, HAV like virus with single standed RNA genome. All HEV isolates appear to belong to a single serotype.

Table: Epidemiological and clinical features of various hepatitis.

                                    HAV                            HBV                                  HCV                           HDV                                 HEV

Incubation (days)    15-45, mean 30       30-180, mean 60-90     15-160, mean 50     30-180, mean 60-90    14-60, mean 40

Transmission

  Feco-oral                 + + +                           —                                       —                                —                                     + + +

  Sexual                     ±                                  + +                                     ±                                  + +                                    —

  Percutaneous         Unusual                     + + +                                  + + +                           + + +                                —

  Perinatal                  —                                + + +                                  ±                                  +                                       —

Clinical

  Fulminant                0.1%                           0.1%-1%                          0.1%                           5-20%                             1-2% (10-20% in
                                                                                                                                                                                                pregnant women)

  Chronicity                —                                1-10%                               50-70%                      Common                        —

                                                                                                                   chronic hepatitis     

  Carrier                     —                                0.1-30%                           1.5-3.2%                    Variable                          —

  Cancer                     —                                +                                        +                                  ±                                       —

  Prognosis                Excellent                   Worse with age               Moderate                   Chronic poor                  Good

Prophylaxis              Inactivated vaccine HBIg                                  None                          HBV vaccine                  —

                                    Ig                                 Recombinant vaccine                                      

Treatment                None                          Interferon                         Interferon                  Interferon                        None

                                                                        Lamivudine                     Ribavirin

44.    Which one of the following is best avoided  in the treatment of acute pancreatitis?

A.   Antibiotics                                                                                 B.    Nasogastric suction

C.   Anticholinergics                                                                       D.    Morphine

Ans. C  (Harrison 16th ed., p 1899)

Anticholinergics are avoided in management of acute pancreatitis. See Q 45 paper 1 UPSC 1999 for further details.

45.    Intrinsic factor for absorpition of vitamin B12 is secreted by the:

A.   Parietal cells                                                                              B.    Peptic cells

C.   Chief cells                                                                                 D.    Goblet cells

Ans. A  (Harrison 16th ed., p 602)

Intrinsic factor is secreted by parietal cell, lack of which leads to vitamin B12 deficiency. It is seen in type A chronic gastritis, which leads to pernicious anaemia.

46.    Which one of the following statements about H. pylori is not true?

A.   Its prevalence increases with age

B.   Its prevalence is inversely related to socio-economic status

C.   Commonly, fundus is the site of colonization

D.   It is implicated in duodenal ulcer, gastric ulcer and gastric carcinoma

Ans. C  (Harrison 16th ed., p 1749)

The initial site of colonization of H. pylori is antrum of stomach and then it spreads gradually proximally. Rest of the three statements are correct. It is also associated with gastric MALT lymphoma. The various risk factors for development of H. pylori infection are:

a.  Low socioeconomic status.

b.  Domestic overcrowding.

c.  Unhygienic living conditions.

d.  Drinking unclean water.

e.  Exposure to gastric content of infected person.

47.    Consider the following statements:

         Delayed gastric emptying (gastroparesis) is seen in:

1.   Hypokalaemia                                                                         2.     Diabetes

3.   Anticholinergic drug therapy                                                 4.     Reflux oesophagitis

         Of these statements:

A.   1 and 2 are correct                                                                  B.    2, 3 and 4 are correct

C.   1, 2 and 3 are corect                                                               D.    1, 3 and 4 are correct

Ans. C 

Hypokalaemia causes paralytic ileus and causes loss of muscle tone and flaccid paralysis and hence it can delay gastric emptying.

Diabetes by causing autonomic neuropathy may lead to gastroparesis. Cholinergic stimulation leads to gastric emptying and intestinal movement and hence anticholinergic drugs will cause gastroparesis.

48.    Which of the following are characteristic of nephrotic syndrome?

1.   Massive proteinuria                                                                2.     Hypoproteinaemia

3.   Hyponatraemia                                                                       4.     Generalised oedema

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    2, 3 and 4

C.   1. 3 and 4                                                                                  D.    1, 2 and 4

Ans. D  (Harrison 16th ed., p 1684)

Nephrotic syndrome consists of proteinuria of >3.5 g/1.73 m2 per 24 hours, hypoalbuminaemia, oedema, hyperlipidaemia, lipiduria and hypercoagulability. However the main component is massive proteinuria, which is due to altered permeability of the glomerular filtration barrier for protein.

Hyponatraemia is not a part of nephrotic syndrome.

49.    Polyuria is a feature of all of the following except:

A.   Hypocalcaemia                                                                       B.    Hypokalaemia

C.   Lithium toxicity                                                                       D.    ADH deficiency

Ans. A  (Harrison 16th ed., p 251)

Polyuria is defined, as 24-hour urine volume greater than 3 litres. Hypocalcaemia does not cause polyuria. Hypercalcaemia causes polyuria by solute diuresis. Solute diuresis is also seen with glucose, mannitol, hypokalaemia, radiocontrast agent, urea, resolving ATN, diuretics etc.

Lithium causes nephrogenic diabetes insipidus and hence polyuria. ADH deficiency causes central diabetes insipidus. The various causes are postoperative (removal of pituitary), trauma, supra- or intrasellar tumour, Sheehan’s syndrome, infections etc.

50.    Which of the following are the features of minimal change glomerulonephritis?

1.   Highly selective proteinuria                                                   2.     Good response to steroid therapy

3.   Occurrence two weeks after sore throat                              4.     Commonly seen in children

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 4                                                                                  B.    2 and 3

C.   1, 2 and 3                                                                                  D.    1, 3 and 4

Ans. A  (Harrison 16th ed., p 1685)

Minimal change glomerulonephritis mainly occurs in children. Highly selective proteinuria is the main feature. It responds very well to steroid and has a good prognosis. See Q 101 paper 1 UPSC 1999 for further details. However according to Nelson all the four statements are correct.

The following diseases are known to occur after respiratory tract infections:

1.  Poststreptococcal glomerulonephritis.

2.  Rheumatic fever.

3.  Minimal lesion glomerulonephritis.

4.  Henoch-Schonlein purpura.

5.  Guillain-Barre syndrome.

6.  IgA nephropathy.

51.    Investigations in a patient of oliguria revealed:

Urine osmolality: 620 mosm/kg

Urinary sodium: 12 mmol/L

Urine/plasma urea ratio: 13 : 1

         The most likely diagnosis is:

A.   Prerenal acute renal failure                                                    B.    Acute tubular necrosis

C.   Acute cortical necrosis                                                            D.    Urinary tract obstruction

Ans. A  (Harrison 16th ed., p 1649)

The patient is suffering from pre-renal renal failure.

According to Kumar and Clark 4th ed., p 568 in prerenal azotemia urine sodium is < 20 mmol/L and in intrinsic renal failure urine sodium is > 40 mmol/L. See also Q 77 paper 1 UPSC 2001 for further details.

52.    Which of the following drugs are used in the treatment of Parkinson’s disease?

1.   Anticholinergic drugs                                                              2.     Selegiline

3.   Butyrophenones                                                                      4.     Phenothiazines

         Select the correct answer using the codes given below:

Codes:

A.   2 and 3                                                                                      B.    1 and 2

C.   1 and 4                                                                                      D.    1, 2, 3 and 4

Ans. B  (Harrison 16th ed., p 2410-2411)

The various anticholinergic drugs in use are benztropine (0.5-2 mg TID), trihexphenidyl (2-5 mg TID), biperidin (1-3 mg QID), orphenadrine (100 mg TID), procyclidine (2.5-10 mg TID) etc. Treatment is started in a low dose and gradually increased till desired effect is achieved.

Selegeline is a MAO-B inhibitor (selective). It reduces oxidative damage and may inhibit the progression of Parkinsonism. It is given in a dose of 5 mg BD.

However the main drug for Parkinsonism is levodopa, which is a precursor of dopamine. It is combined with peripheral dopa-decarboxylase inhibitor (carbidopa or benserazide). See Q 84 paper 1 UPSC 2001 for clinical features of Parkinsonism.

53.    Which one of the following regions of the body has the largest representation in cortical area 4?

A.   Trunk muscle                                                                           B.    Muscles of forearm

C.   Muscles of mastication                                                          D.    Muscles of thumb

Ans. D  (Ganong 18th ed., p 193)

The cortical representation of each body part is proportional in size to the skill with which part is used in fine, voluntary movement.  The area involved in speech and hand movements are especially large in the cortex. Use of the pharynx, lips and tongue to form words and of the fingers and opposable thumb to manipulate the environment are activities in which humans are especially skilled.

54.    Sudden loss of vision occurs in all of the following except:

A.   Retrobulbar neuritis                                                                B.    Central retinal artery occlusion

C.   Papilloedema                                                                           D.    Retinal detachment

Ans. C  (Parsons’ Diseases of the Eye 19th ed., p 367-372)

In papilloedema there is oedema of the optic disc or nerve head due to raised intracranial preesure. Elevated CSF pressure produces axoplasmic stasis in the optic nerve head leading to swelling of the optic disc and secondary vascular changes at the disc surface.

Papilloedema is characterized by blurring of margins of the optic disc. It starts at the upper and lower margins and extends around the nasal side. Temporal margins are usually visible sharp. For long, the vision may be unimpaired particularly central vision. Transient attacks of blurred vision may occur in early stages but with progressive enlargement of blind-spot, progressive contraction of visual field (due to atrophy of nerve) occurs.

Sudden loss of visual acuity occurs in occlusion of central retinal artery, optic neuritis, papillitis, retrobulbar neuritis, vitreous or retinal haemorrhage, retinal detachment, acute congestive glaucoma, quinine poisoning, methyl alcohol poisoning, temporal arteritis, optic nerve injury, brain injury, brain stem arteriovenous malformations, meningeal carcinomatosis.

55.    All of the following statements regarding the oculomotor nerve are true except:

A.   It accommodates the eye                                                      B.    It raises the upper eyelid

C.   It innervates lateral rectus                                                     D.    It constricts the pupil

Ans. C  (Parsons’ Diseases of the Eye 19th ed., p 427, 466)

Lateral rectus is innervated by the 6th nerve.

In complete paralysis of the third nerve there is ptosis (which prevents diplopia), semidilated and immobile pupil and paralysis of accommodation. Slight degree of proptosis may occur due to loss of tone of the paralysed muscles. There is limitation of movement upwards and inwards, on raising the lid eye is seen to be deflected outwards and rotated internally owing to tone of two unparalysed muscles (lateral rectus and superior oblique).

Remember: (LR6SO4)3: Lateral rectus is supplied by 6th nerve. Superior oblique is supplied by 4th nerve. Rest of the extraocular muscles are supplied by 3rd nerve.

56.    Hemianopia, cortical blindness, amnesia and thalamic pain are associated with the occlusion of:

A.   Anterior cerebral artery                                                          B.    Middle cerebral artery

C.   Posterior cerebral artery                                                         D.    Basilar artery

Ans. C  (Harrison 16th ed., p 2384-2385)

Occlusion of posterior cerebral artery leads to the following:

a.  Peripheral territory: Homonymous hemianopia, cortical blindness, awareness or denial of blindness, failure to see to and fro movements, apraxia of ocular movements, colour anomia, memory defect, hemivisual neglect, visual hallucinations etc.

b.  Central territory: Thalamic syndrome, spontaneous pain and dysaesthesia, intention tremor, Claude’s syndrome, Weber’s syndrome, contralateral hemiplegia etc.

57.    An 80-year old person has started forgetting the names of familiar persons and places. There has been no confabulation. He tends to forget whether he had his meals. Clinical and neurological examination reveal no abnormality. CT scan of the brain showed symmetrical enlargement of lateral ventricles and wide sulci. The most likely diagnosis is:

A.   Confusional state                                                                    B.    Alzheimer’s disease

C.   Alcohol dementia                                                                    D.    Chronic cerebrovascular insufficiency

Ans. B  (Harrison 16th ed., p 2398)

The described clinical picture is typical of Alzheimer’s disease. In Western countries it is the commonest cause of dementia. The main feature is loss of memory, which is gradually progressive in nature.

Pathologically the most important features are ‘senile plaques’ and ‘neurofibrillary tangles’, which are most commonly seen in hippocampus, temporal cortex and nucleus basalis. PET scanning has shown that the earliest change occurs in parietal cortex.

Tacrine and donepezil are the only two drugs approved for treatment.

58.    A 40-year old woman presented with a CT scan of head showing an enlarged sella turcica. Neurological and endocrine work up in detail were found to be normal. The most likely diagnosis is:

A.   Prolactinoma                                                                            B.    Chromophobe adenoma

C.   Craniopharyngioma                                                               D.    Empty sella syndrome

Ans. D  (Harrison 16th ed., p 2079)

The patient is most probably suffering from empty sella syndrome. This is usually a MRI or CT finding. They have normal pituitary function and there are no neurological symptoms or deficit.

Hypopituitarism may develop insidiously.

Sometimes there is silent infarction of pituitary and the sella is filled up with CSF but in these cases endocrine abnormalities are seen.

59.    A 16-year old female presents with generalised weakness and palpitations. Her Hb is 7 g/dl and peripheral smear shows microcytic hypochromic anaemia; reticulocyte count = 0.8%, serum bilirubin = 1 mg%. The most likely diagnosis is:

A.   Iron deficiency anaemia                                                        B.    Haemolytic anaemia

C.   Aplastic anaemia                                                                    D.    Folic acid deficiency

Ans. A  (Harrison 16th ed., p 588-589)

The patient is suffering from iron deficiency anaemia. Microcytic hypochromic anaemia is found in:

1.  Iron deficiency.

2.  Thalassaemia.

3.  Sideroblastic anaemia.

In this patient reticulocyte count is normal which excludes thalassaemia and haemolytic anaemia in which reticulocyte count is raised. There are no features suggestive of sideroblastic anaemia.

In aplastic anaemia there is normochromic and normocytic anaemia.

In folic acid deficiency there is megaloblastic anaemia.

60.    A 55-year old male presents with enlarged glands over the left side of the neck. On examination, spleen is enlarged 4 cm below the costal margin and liver is enlarged 2 cm below costal margin. Blood examination shows a total leucocyte count of 80,000/cumm, mostly lymphocytes and a few premature cells. The most likely diagnosis is:

A.   Infective adenopathy                                                             B.    Acute leukaemoid reaction

C.   Lymphatic leukaemia                                                            D.    Hodgkin’s disease

Ans. C  (Harrison 16th ed., p 648)

The patient is suffering from chronic lymphocytic leukaemia (CLL), which is the commonest leukaemia of old age. Lymphadenopathy with hepatosplenomegaly further points towards CLL. The peripheral blood picture in CLL shows leucocytosis with lymphocytosis as the main abnormality. Sometimes autoimmune haemolytic anaemia may be found in these patients.

CLL is of B cell origin and displays CD5 antigen.

Chemotherapy is not given in majority as CLL has a slow indolent course. Chlorambucil or fludarabine are used, as single agent for chemotherapy and fludarabine is the drug of choice.

61.    An elderly person has been having refractory anaemia with pancytopenia. The peripheral smear shows ring sideroblasts and 15% blast cells. The bone marrow is hypercellular. The most likely diagnosis is:

A.   Myelodysplastic syndrome                                                   B.    Acute myelogenous leukaemia

C.   Blast crisis of chronic myeloid leukaemia                          D.    Malignant infiltration of bone marrow

Ans. A  (Harrison 16th ed., p 624-625)

The patient is suffering from myelodysplastic syndrome (MDS). It is characterized by cytopenias with dysmorphic and usually cellular bone marrow and ineffective blood cell production.

Idiopathic MDS is a disease of old persons. The main feature is refractory anaemia. Fever and weight loss may be present. 20% patients have splenomegaly.

Refractory anaemia with pancytopenia is the main abnormality. Ringed sideroblasts are also seen. The number of blast cells is more than 5% in blood and between 20-30 percent in bone marrow in ‘refractory anaemia with excess blasts in transformation’ subtypes of MDS.

In blast crisis the number of blasts in marrow or peripheral smear is more than 20%.

Treatment is unsatisfactory and only stem cell transplantation offers cure.

62.    Which one of the statements about non-insulin dependents diabetes mellitus (NIDDM) is not true?

A.   Circulating islet cell antibodies are usually found

B.   There is no HLA association

C.   Ketosis is rare

D.   Relative resistance to insulin is present

Ans. A  (Harrison 16th ed., p 2156)

Circulating islet cell autoantibodies are a composite of several antibodies directed at pancreatic islet molecules such as GAD (glutamic acid decarboxylase), insulin, IA-2/ICA512 and an islet ganglioside and they serve as marker of autoimmune process in type IA DM.

These are present in more than 75% of newly diagnosed type IA DM within 5 years.

Rest of the statements in the question are true for type 2 DM (NIDDM).

63.    Consider the following features:

1.   Hyperthyroidism                                                                     2.     Pretibial myxoedema

3.   Atrial fibrillation                                                                      4.     Ophthalmopathy

         Those which are characteristic of Graves’ disease would include:

A.   1, 3 and 4                                                                                  B.    2, 3 and 4

C.   1, 2 and 3                                                                                  D.    1, 2 and 4

Ans. D  (Harrison 16th ed., p 2113)

The three main features of Graves’ disease are goitre with hyperthyroidism, ophthalmopathy and dermopathy (pretibial myxoedema).

Hyperthyroidism is due to thyroid stimulating antibodies. Ophthalmopathy and dermopathy are due to immunologically mediated activation of fibroblasts in extraocular muscles and skin that lead to accumulation of glycosaminoglycans, which in turn lead to oedema.

Atrial fibrillation is a feature of thyrotoxicosis, which is also seen in Graves’ disease.

64.    Which of the following antidiabetic drugs are particularly to be avoided in elderly diabetic patients?

1.   Glibenclamide                                                                          2.     Gliclazide

3.   Chlorpropamide                                                                      4.     Glipizide

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    1 and 3

C.   2 and 4                                                                                      D.    1, 3 and 4

Ans. B  (Harrison 16th ed., p 2175)

Glibenclamide and chlorpropamide are better avoided in elderly patients because they have greater incidence of hypoglycaemia and frequent drug interaction. The second-generation sulfonylureas (gliclazide, glipizide, glimepiride, glyburide etc) are preferred in elderly persons.

65.    Wermer’s syndrome (multiple endocrine neoplasia type I) is characterised by all of the following except:

A.   Tumours of anterior pituitary                                               B.    Tumours of parathyroids

C.   Pancreatic adenomas                                                             D.    Phaeochromocytoma

Ans. D  (Harrison 16th ed., p 2231)

Pheochromocytoma is seen in MEN type 2. It is rare in MEN type 1. See also Q 20.

66.    Periodic paralysis may be associated with all of the following except:

A.   Hyperkalaemia                                                                        B.    Hypokalaemia

C.   Hyperthyroidism                                                                     D.    Hypothyroidism

Ans. D  (Harrison 16th ed., p 2536-2537)

Periodic paralysis means episodic muscle weakness followed by recovery. Each episode lasts for few hours to several days and may occur daily or once in four years.

Hypokalaemia (mutation in voltage sensitive, skeletal muscle calcium channel), hyperkalaemia and thyrotoxicosis are known causes of periodic paralysis.

Acetazolamide and IV/oral K+ suplementation is used in management of hypokalaemic periodic paralysis.

Remember the following important points commonly asked in examination:

1.  High carbohydrate diet provokes hypokalemic periodic paralysis.

2.  Hyperkalemic periodic paralysis is a disorder of sodium channel of muscles. In 50% of patients serum K+ is moderately elevated but it may be normal or low.

3.  Myotonia congenita occurs due to Cl– channel disorder of muscles.

4.  Paramyotonia congenita is a sodium channel disorder of muscle.

5.  In thyrotoxic periodic paralysis there is evidence of decreased activity of calcium pump. Acute attacks respond to potassium. Beta blockers prevent attacks and acetazolamide is not useful.

67.    Vitamin D resistant rickets is associated with:

A.   Hypophosphataemia                                                             B.    Increased calcium absorption

C.   Metabolic acidosis                                                                  D.    Renal failure

Ans. A  (Harrison 16th ed., p 1700)

Vitamin D resistant rickets is an X-linked dominant disorder in which there is defective renal tubular phosphate reabsorption with hypophos­phataemia that leads to rickets. The vitamin D level is relatively low for the degree of hypophosphataemia. Treatment is with very high dose of vitamin D and oral phosphate.

Hypophosphataemia is mainly due to reduced tubular reabsorption of phosphate, low intestinal absorption also contributes. The features are bow legs, delayed dentition, skull abnormalities, short stature etc. The serum calcium is normal. Vitamin D level is also normal which should have been elevated in presence of hypo­phosphataemia.

68.    A patient after vomiting several times develops carpopedal spasm. The most appropriate treatment would be:

A.   Intravenous injection of 20 ml 10% calcium gluconate solution

B.   Intravenous infusion of isotonic saline

C.   Oral ammonium chloride 2 gm four times a day

D.   5% CO2 inhalation

Ans. A 

The patient has developed carpopedal spasm. This means he has tetany, which has developed due to alkalosis (due to loss of acid in vomitus) that leads to decreased level of serum ionized calcium.

There are three parts in management. The first part is immediate management of tetany, second part is correction of alkalosis and third part is correction of cause of vomiting.

For immediate control of tetany IV 20 ml of 10% calcium gluconate is given.

For alkalosis the best approach is to give IV NS. Ammonium chloride and 5% CO2 inhalation are other alternatives.

For vomiting metoclopramide with ranitidine may be given.

69.    Which one of the following is AIDS defining illness?

A.   Mycobacterium tuberculosis meningitis                             B.    Cryptococcus neoformans meningitis

C.   Cytomegalovirus meningitis                                                  D.    Histoplasma capsulatum meningitis

Ans. B  (Harrison 16th ed., p 1116)

Cryptococcal meningitis is the initial AIDS defining illness in about 2% of cases and it usually occurs in patients with CD4+ T cell count <100/µL.

The features are fever, vomiting, altered sensorium, headache, neck rigidity etc. About 1/3rd of patients have pulmonary cryptococcosis.

India ink examination of CSF helps in diagnosis. Treatment is with IV amphotericin B (0.7 mg/kg OD) with flucy-tosine (25 mg/kg QID) for 14 days followed by fluconazole 400 mg/d orally for 8 weeks followed by 200 mg/d for life.

70.    Which one of the following vectors transmits scrub typhus?

A.   Louse                                                                                         B.    Flea

C.   Mite                                                                                            D.    Ticks

Ans. C  (Harrison 16th ed., p 1004)

Scrub typhus is caused by Orientia tsutsugamushi, which is maintained in nature by transovarian transmission in trombiculid mites, mainly of genus Leptotrombidium.

After hatching, the infected larval mites (chigger) inoculate organisms into the skin while feeding.

Clinical features are fever, headache, myalgia, cough, gastrointestinal symptoms, regional lymphadenopathy etc.

Doxycycline (100 mg BD for 15 days) or chloramphenicol (500 mg QID for 15 days) is used for treatment.

71.    Which one of the following organisms is responsible for toxin mediated food poisoning?

A.   Bacillus anthracis                                                                   B.    Salmonella species

C.   Staphylococcus aureus                                                          D.    Campylobacter jejuni

Ans. C  (Ananthnarayan and Paniker 6th ed., p 182, 233)

Most likely cause is Staphylococcal food poisoning, which is due to preformed toxin. Incubation period is 1 to 6 hours and is characterised by sudden onset of vomiting, abdominal cramps and diarrhoea.

Food poisoning is classified into three types depending upon the pathogenesis.

a.  Infection type: In this type the infective dose of pathogenic microorganism is ingested. The incubation period is 12 to 24 hours. Typical example is Salmonella food poisoning. Man gets the infection from farm animals and poultry.

b.  Toxin type: Here the patient consumes preformed toxin present in food.The incubation period is short, 1 to 6 hours. Typical example is Staphylococcal food poisoning. The foods involved are salads, custards, milk and milk products which get contaminated by staphylococci. Food poisoning results from ingestion of toxins preformed in food in which bacteria have grown. Since the toxin is heat resistant, it can remain in food after the organisms have died. Patient presents with sudden onset of vomiting, abdominal cramps and diarrhoea.

c.  Intermediate type: In this case the ingested pathogenic bacteria liberates toxin in gut and causes diarrhoea.The incubation period is 6 to 12 hours. Typical example is Clostridium perfringens food poisoning. Cl. perfringens food poisoning outbreaks are associated with ingestion of meat, meat dishes and poultry. Usual story is that the food has been prepared and cooked 24 hours or more before consumption and allowed to cool slowly at room temperature and then heated immediately prior to serving. Nausea and vomiting are rare in Clostridium food poisoning.

72.    Type II lepra reaction is seen in which of the following conditions?

1.   Lepromatous leprosy                                                              2.     Borderline leprosy

3.   Intermediate leprosy                                                               4.     Tuberculoid leprosy

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    2 and 4

C.   1 and 3                                                                                      D.    3 and 4

Ans. A  (Harrison 16th ed., p 969)

Type 2 lepra reaction

Type 2 lepra reaction i.e., erythema nodosum leprosum (ENL) occurs in lepromatous and borderline lepromatous leprosy. ENL may precede the diagnosis of leprosy.

Commonly it presents in the form of crops of painful erythematous papules that resolve spontaneously in a few days to a week.

Skin biopsy reveals vasculitis or panniculitis. TNF level is raised.

Treatment is with short course of glucocorticoid (40-60 mg/day for 7 to 14 days). In recurrent or persistent cases thalidomide is given.

Type 1 lepra reaction

Type 1 lepra reaction is seen in about 50% case of borderline leprosy but not in patients with polar disease. There is low grade fever, ulnar nerve is thickened and tender, there is inflammation in previously involved macules, papules and plaques. Oedema is most characteristic microscopic feature of type 1 lepra reaction.

Treatment is with glucocorticoid.

73.    The treatment of choice in resistant malaria is:

A.   Chloroquine                                                                              B.    Quinine

C.   Primaquine                                                                               D.    Tetracycline

Ans. B  (Harrison 16th ed., p 1226)

Resistance of P. vivax to chloroquine is not yet a major problem but it is a very big problem as far as P. falciparum is considered.

Drug resistant malaria is treated with quinine. In USA quinidine is more commonly used. The oral dose of quinine is 10 mg of salt/kg 8 hourly for 7 days and the intravenous dose is 20 mg of salt/kg over 4 hours followed by 10 mg/kg 8 hourly over 2-8 hours for 7 days.

The various other drugs used in drug resistant malaria are sulfadoxine + pyrimethamine, mefloquine, artesunate, artemethers, halofantrine etc.

74.    The treatment of choice in Taenia saginata and Taenia solium infections is:

A.   Metronidazole                                                                          B.    Niclosamide

C.   Praziquantel                                                                             D.    Albendazole

Ans. C  (Harrison 16th ed., p 1273-1274)

The treatment of choice for Taenia saginata and Taenia solium is praziquantel. A single dose of 5-10 mg/kg is sufficient. However in case of Taenia solium one has to be careful because praziquantel can evoke inflammatory response in CNS if concomitant cryptic neurocysticercosis is present.

However according to Kumar and Clark 4th ed., p 95 niclosamide is mentioned as treatment along with praziquantel. Previously niclosamide was used extensively but now praziquantel is considered to be highly effective though it is not available all over the world. Harrison does not even mention about niclosamide.

75.    An Indian adult who has never travelled abroad comes with a history of high fever, headache, jaundice, marked oliguria and shock with TLC of 16,000/cumm. The most likely diagnosis is:

A.   Viral hepatitis                                                                           B.    Leptospirosis (Weil’s disease)

C.   Yellow fever                                                                             D.    Haemolytic uraemic syndrome

Ans. B  (Harrison 16th ed., p 990)

The patient has developed leptospirosis. For further details see Q 101 paper 1 UPSC 2001.

76.    Which one of the following drugs causes hyperprolactinaemia?

A.   Domperidone                                                                           B.    Metoclopramide

C.   Cisapride                                                                                   D.    Lansaprazole

Ans. B  (Harrison 16th ed., p 2085)

Drug induced inhibition of dopaminergic receptors result in hyperprolactinaemia. Metoclopramide is a common drug to cause hyperprolactinaemia.

Besides metoclopramide the other drugs that cause hyperprolactinaemia are phenothiazines, butyrophenones (haloperidol), thioxanthenes, alpha methyldopa, reserpine, cimetidine, ranitidine, amitryptyline, fluoxetine, verapamil, oestrogen, antiandrogens etc.

In all cases of unexplained glactorrhoea always drug history needs to be taken carefully.

77.    Consider the following adverse effects of penicillin:

1.   Haemolysis                                                                               2.     Drug fever

3.   Neutropaenia                                                                           4.     Anaphylaxis

         Those related to dose of penicillin are:

A.   1 and 2                                                                                      B.    1 and 3

C.   2 and 4                                                                                      D.    3 and 4

Ans. B 

The greatest concern for beta lactams is the allergic reactions. The types of reactions are:

l   Type 1 hypersensitivity: Anaphylaxis.

l   Type 2 hypersensitivity, cytotoxic reaction: Nephritis and Coombs’ positive haemolytic anaemia.

l   Type 3 hypersensitivity, immune complex formation: Drug fever and serum sickness.

l   Type 4 hypersensitivity, cell mediated effects: Contact dermatitis.

l   Type 5 hypersensitivity, idiopathic reaction: Maculopapular eruptions.

Table: Adverse effects of penicillin.

       Hypersensitivity                                                                                                     Dose related

–    Skin rash (urticaria/maculopapular)                                                             –    Neutropenia, reversible

–    Anaphylaxis                                                                                                       –    Haemolysis

–    Drug fever                                                                                                          –    Encephalopathy

–    Interstitial nephritis

Sometimes seizures are also seen with penicillin (high dose).

78.    Alcohol ingestion may give rise to disulfiram type reactions with:

A.   Hydroxyquinolone                                                                  B.    Furazolidine

C.   Sulphonamide                                                                          D.    Metronidazole

Ans. D  (Harrison 16th ed., p 803)

Disulfiram like reactions occur due to inhibition of enzyme aldehyde dehydrogenase, which leads to accumulation of aldehyde, which is an intermediate product in metabolism of alcohol. It causes a very unpleasant reaction in presence of alcohol. Hence disulfiram is used for deaddiction from alcohol.

Metronidazole produces disulfiram like side effect in alcoholics.

79.    Consider the following factors:

1.   HIV                                                                                            2.     Malignancy

3.   Systemic lupus erythematosus                                             4.     Glomerulonephritis

         Those factors which predispose to candidiasis would include:

A.   1 and 2                                                                                      B.    2 and 3

C.   3 and 4                                                                                      D.    1 and 4

Ans. A  (Harrison 16th ed., p 1186)

Candidiasis occurs mainly in immunocompromized persons. Various immunosuppressed states like AIDS, malignancy, steroid therapy, diabetes mellitus etc have increased incidence of candida infection.

Candida infection increases after broad-spectrum antibiotic therapy. Vulvovaginal candidiasis is common in third trimester of pregnancy. Cutaneous candidiasis often involves macerated skin such as diapered area of infants, hands constantly in water etc. Neutropenia is also an important risk factor for candidiasis.

80.    Healing with calcification is a feature of:

A.   Cryptococcosis                                                                        B.    Mucormycosis

C.   Aspergillosis                                                                              D.    Histoplasmosis

Ans. D  (Harrison 16th ed., p 1179)

Healing with calcification is a feature of histoplasmosis. For further information see Q 47 paper 1 UPSC 2002 and Q 9 paper 1 UPSC 2000.

81.    Which one of the following signs is most valuable in the diagnosis of Wernicke’s encephalopathy?

A.   Ataxia

B.   Confusional state

C.   Korsakoff’s psychosis

D.   Bilateral symmetrical ophthalmoplegia

Ans. D 

The most valuable sign of Wernicke’s encephalopathy is some form of bilateral, symmetrical ophthalmoplegia. This may be in one or more than one direction and accompanied by nystagmus and/or abnormal pupillary reflexes.

See also Q 6 paper 1 UPSC 2003.

It should be treated on emergency basis. 50 mg of thiamine hydrochloride should be given IV followed by 50 mg daily IM for a week.

82.    Match List-I (Nutrients) with List-II (Clinical effects/roles) and select the correct answer using the codes given below the Lists:

       List-I                                                                                  List-II

a.   Copper                                                                       1.     Eczematous dermatitis around nose and mouth

b.   Tocopherol                                                               2.     Antioxidants

c.    Zinc                                                                            3.     Increased density of bone

d.   Fluoride                                                                     4.     Chronic liver disease

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       4     2     1     3                    4     2     3     1                  2      4       3      1                    2      4    1    3

Ans. A 

Copper accumulation in liver is a feature of Wilson’s disease. Chronic liver disease with hepatic failure is a major clinical feature.

Tocopherol (vitamin E) is a well known antioxidant. It protects body from oxygen derived free radials.

Zinc deficiency leads to dermatitis around mouth and nose. See also Q 44 paper 1 UPSC 2002.

Excess fluoride consumption leads to fluorosis. It leads to increased density of bone. Chalky white bones are seen in X-ray.

83.    A 30-year old male presents with pruritic flat-topped polygonal, shiny violanceous papules with flexural distribution. The most likely diagnosis is:

A.   Psoriasis                                                                                     B.    Pityriasis rosea

C.   Lichen planus                                                                           D.    Lichenoid dermatitis

Ans. C  (Short Textbook of Dermatology and Venereology 1st ed., Praveen Jain p 53)

The clinical feature is typical of lichen planus. Wickham’s striae and Koebner’s phenomenon are seen in it.

Lichen planus is characterized by:

l   Flat topped polygonal greyish white or purple eruptions.

l   Eruptions have scaly surface and is traversed by fine white lines, called Wickham’s striae.

l   Papule may be scattered or grouped.

l   Papules may be linear over marks of excoriation or trauma (Koebner’s phenomenon).

l   Involves flexor surfaces or wrist and forearms, lumbar area, ankles, glans penis, anterior aspect of lower legs and dorsal surfaces of the hands.

l   Mucous membrane involved in 50% cases.

l   Nails involved in 10% cases. Most common nail change is slight thinning of nail plate.

l   Civatte bodies or colloid bodies which are necrotic keratinocytes are seen.

l   Max-Joseph space: This is a clear area, seen at dermoepidermal junction in lichen planus.

l   Lichen planus of hair follicle is known as lichen planopilaris causing scarring alopecia (Pseudopelade).

l   Conditions associated with lichen planus are alopecia areata, morphea, vitiligo, ulcerative colitis, myasthenia gravis and other autoimmune disorders.

84.    Chancroid (soft sore) is caused by:

A.   Haemophilus ducreyi                                                             B.    Treponema pallidum

C.   Treponema pertenue                                                               D.    Borrelia recurrentis

Ans. A  (Harrison 16th ed., p 866)

Haemophilus ducreyi causes chancroid. It is a gram-negative bacterium that requires X factor (hemin) for growth.

Chancroid is a STD. After incubation period of 4 to 7 days a papule appears in genitalia, which gets converted into painful ulcers that bleeds easily. Tender inguinal lymphadenopathy is seen in 50% cases.

Ceftriaxone 250 mg IM single dose, azithromycin 1g orally single dose or ciprofloxacin 500 mg BD for 3 days may be given.

Treponema pallidum causes syphilis.

Treponema pertenue causes yaws.

Borrelia recurrentis causes louse borne relapsing fever.

85.    Lilac coloured (heliotrope) pigmentation over the face is characteristic of:

A.   Dermatomyositis                                                                     B.    Polymyositis

C.   Systemic lupus erythematosus                                             D.    Systemic sclerosis

Ans. A  (Harrison 16th ed., p 2540)

Dermatomyositis is an inflammatory myopathy. It affects both adults and children and more commonly women than men.

The main feature is progressive and symmetric muscle weakness. In dermatomyositis there is heliotrope (lilac coloured, bluish purple coloured) rash on upper eyelids with oedema, and erythema of knuckles with raised violaceous scaly eruption (Grotton’s rash).

In up to 15% of cases there is increased risk of malignancy. Serum CK is elevated 50 times. Muscle biopsy confirms diagnosis. It should be differentiated from polymyositis.

Prednisolone and immunosuppressive drugs are used in treatment.

86.    All of the following can be used to prevent gouty attack except:

A.   Allopurinol                                                                                B.    Aspirin

C.   Probenecid                                                                                D.    Sulfinpyrazone

Ans. B  (Harrison 16th ed., p 2047)

Aspirin is a NSAID and it is used to treat acute attack of gout. See Q 62 paper 1 UPSC 2002 for further information.

87.    A young male presens with joint pains and backache. X-ray of spine shows evidence of sacroilitis. The most likely diagnosis is:

A.   Rheumatoid arthritis                                                               B.    Ankylosing spondylosis

C.   Polyarticular juvenile arthritis                                               D.    Psoriatic arthropathy

Ans. B  (Harrison 16th ed., p 1994)

Sacroilitis is a classical feature of ankylosing spondylitis that affects young adults. See also Q 49 paper 1 UPSC 2002.

Ankylosing spondylitis is commonly seen in young male and it is associated with HLA B27. Sacroilitis is the main feature in the early part of the disease. Gradually the spine is involved. There are features of both enthesitis and synovitis.

There is subchondral granulation tissue with infiltration of inflammatory cells. Synovitis follows with pannus formation. Iliac cartilage is eroded before thicker sacral cartilage and gradually the joint space may be obliterated.

TNF alpha antagonists are now the drug of choice for ankylosing spondylitis.

88.    A young female is suffering from recurrent thrombosis of leg vein, abortion, thrombocytopaenia and focal neurological lesions. The most likely diagnosis is:

A.   Disseminated intravascular coagulation                             B.    Systemic lupus erythematosus

C.   Syphilis                                                                                      D.    Vasulitis

Ans. B  (Harrison 16th ed., p 1963)

The patient is suffering from SLE. See Q 117 paper 1 UPSC 2001 for clinical features of SLE.

89.    Lithium carbonate is the drug of choice in:

A.   Anxiety neurosis                                                                      B.    Conversion reaction

C.   Manic depressive psychosis                                                  D.    Schizophrenia

Ans. C  (Niraj Ahuja 5th ed., p 72)

Lithium is the drug of choice for manic episode as well as for the recurrent manic depressive attacks. The preventive use is best in usually those bipolar patients where the frequency of episodes is 1-3 per year or 2-5 per two years. Before starting treatment, it is essential to make sure of normal functioning of kidneys, thyroid, heart and CNS. There is a 1-2 weeks lag period before any appreciable response is observed. The usual dose is 900-1200 mg of lithium carbonate per day. The treatment is closely monitored by repeated blood levels as the difference between therapeutic and lethal blood levels is not very wide.

90.    A middle-aged patient was brought to the hospital in stuporous condition with loss of power in all four limbs. Waxy flexibility of muscle tone in the limbs was detected. The most likely diagnosis is:

A.   Hysterical stupor                                                                     B.    Organic stupor

C.   Catatonic stupor                                                                      D.    Depressive stupor

Ans. C  (Niraj Ahuja 5th ed., p 56)

The patient is suffering from catatonic schizo­phrenia. Waxy flexibility means that the patent will keep his body parts in a certain posture for a long time even if very uncomfortable and flexible like wax.

Catatonic schizophrenia is characterized by marked disturbance of motor behaviour. Important clinical features of catatonia are mutism, rigidity, negativism, posturing, stupor, echolalia, echopraxia, waxy flexi­bility, ambitendency mannerisms, stereo­typies and verbigeration.

91.    Which one of the following disorders is X-linked dominant transmission to the offsprings?

A.   Vitamin D resistant rickets                                                     B.    Nephrogenic diabetes insipidus

C.   Colour blindness                                                                      D.    Christmas disease

Ans. A  (Harrison 16th ed., p 1700)

Hypophosphataemic vitamin D resistant rickets is a X linked dominant disorder. Hypophosphataemia is mainly due to reduced tubular reabsorption of phosphate, low intestinal absorption also contributes. The features are bow legs, delayed dentition, skull abnormalities, short stature etc. The serum calcium is normal. Vitamin D level is also normal which should have been elevated in presence of hypo­phosphataemia.

Nephrogenic diabetes insipidus is X-linked recessive disease and another variety of it is autosomal recessive.

Colour blindness is also X-linked recessive disease.

Christmas disease is also X-linked recessive disease.

92.    In the flow of genetic information, transcription is directly involved in the step:

A.   DNA to RNA                                                                            B.    DNA to DNA

C.   RNA to protein                                                                         D.    Protein to RNA

Ans. A  (Harrison 16th ed., p 362-363)

The information stored in DNA code of a gene is transcribed from one strand to a particular type of RNA (messenger RNA) so that each base of mRNA formed is complimentary to corresponding base in DNA of the gene i.e., cytosine with guanine, thymine with adenine but adenine with uracil since uracil replaces thymine in RNA.

Gene transcription starts when RNA polymerase starts synthesizing RNA from DNA template.

Translation is the process of formation of protein from RNA.

93.    Chromosomal localisation is known in which of the following disorders?

1.   Wilson’s disease                                                                       2.     Diabetes mellitus

3.   Whipple’s disease                                                                    4.     Retinitis pigmentosa

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 3                                                                                  B.    1, 2 and 4

C.   1, 3 and 4                                                                                  D.    2, 3 and 4

Ans. B  (Harrison 16th ed., p 1770)

Whipple’s disease has no relation with chromosomes because it is not a genetically transmitted disease. It is caused by bacteria Tropheryma whippelii. It is a small gram-positive bacillus.

The clinical features are diarrhoea, pain abdomen, weight loss, arthropathy, fever, steatorrhoea etc.

It is treated with trimethoprim/sulfamethoxazole for 1 year.

The genetic abnormality in Wilson’s disease, diabetes mellitus and retinitis pigmentosa are well known.

94.    A farmer who worked in the field whole day suddenly took ill and was brought to the hospital with vomiting, diarrhoea, salivation, perspiration, constricted pupils and pulmonary oedema. The most likely diagnosis is:

A.   Acute left ventricular failure                                                 B.    Organophosphorus poisoning

C.   Snake bite                                                                                 D.    Aluminium phosphide poisoning

Ans. B  (Harrison 15th ed., p 2614; 16th ed., p 2589)

The farmer has developed organophosphorous poisoning. Vomiting, diarrhoea, sweating, salivation with constricted pupil are the main clue for organophosphorous poisoning. See Q 4 paper 1 UPSC 2001 for further details.

95.    Match List-I (Poisoning) with List-II (Treatment) and the select the correct answer using the codes given below the Lists:

      List-I                                                                                               List-II

a.   Paracetamol                           1.                                                    Physostigmine

b.   Salicylate                                2.                                                    Potassium chloride

c.   Theophylline                          3.                                                    Acetyl cysteine

d.   Tricyclic antidepressants      4.                                                    Forced alkaline diuresis

Codes:

A.   a     b     c      d              B.   a     b     c      d           C.   a      b       c      d              D.   a      b    c     d

       3     4     2     1                    4     3     1     2                  3      4       1      2                    4      3    2    1

Ans. A 

Paracetamol poisoning is treated with N-acetylcysteine. It is a sulphydryl (SH) group donor and increases hepatic glutathione availability. It is given in a dose of 150 mg/kg in 200 ml of 5% glucose IV over 15 minutes followed by infusion of 50 mg/kg in 500 ml 5% glucose every 4 hourly.

Salicylate poisoning is treated by forced alkaline diuresis. The following is mixed together and given IV at a rate of 2 litres hourly for 3 hours.

l   Normal saline: 0.5 litre.

l   5% dextrose: 1 litre.

l   NaHCO3 (1.26%): 0.5 litre.

l   KCl: 3 g.

Theophylline causes hypokalaemia and hence KCl is required. Activated charcoal, gastric lavage, IV diazepam, control of arrhythmias are the main treatment methods.

Physostigmine salicylate (1-3 mg) is given slow IV to abolish CNS effects of tricyclic antidepressant drugs.

96.    T-lymphocytes function can be tested by delayed hypersensitivity skin testing using which of the following antigens?

1.   Tetanus  toxoid                                                                        2.     PPD

3.   Mumps antigen                                                                        4.     Pneumococcal antigen

         Select the correct answer using the codes given below:

Codes:

A.   1, 2 and 4                                                                                  B.    1, 2 and 3

C.   1, 3 and 4                                                                                  D.    2, 3 and 4

Ans. D  (Anantnarayan and Paniker 6th ed., p 133)

Delayed hypersensitivity and other types of CMI (cell mediated immunity) are mediated by T lymphocytes.

Delayed hypersensitivity skin testing using purified protein derivative for TB, mumps antigen and pneumoccoccal antigen will test T lymphocyte function as they are due to CMI.

CMI participates in following immunological functions:

l   Delayed hypersensitivity.

l   Transplantation immunity and graft-versus-host reaction.

l   Immunological surveillance and immunity against cancer.

l   Pathogenesis of certain antoimmune disease e.g., thyroiditis, encephalomyelitis.

l   Immunity in infectious diseases caused by obligate and facultative intracellular parasites. Infection with:

l   Bacteria e.g., tuberculosis, leprosy, listeriosis, brucellosis, pneumococcus is also an intracellular organism.

l   Fungi: Histoplasmosis, coccidiodomycosis, and blastomycosis.

l   Protozoa: Leishmaniasis, trypanosomiasis.

l   Viruses e.g., measles, mumps.

97.    Transfusing blood after prolonged storage could lead to:

A.   Citrate intoxication                                                                 B.    Potassium intoxication

C.   Circulatory overload                                                               D.    Haemorrhagic diathesis

Ans. B  (Harrison 16th ed., p 666)

During prolonged storage of blood K+ leaks out from RBC. Hence if this blood is transfused to neonates or renal failure patients there is a high risk of hyperkalaemia.

The other electolyte disturbance seen as a complication of blood transfusion is hypocalcaemia. This occurs because citrate used as anticoagulant chelates calcium.

98.    A 15-year old girl presents with history of 7 days high fever, toxic appearance, anaemia, petechiae over skin, ulcers in the mouth and mild hepatosplenomegaly with total count of 30,000/cumm. The most important investigation for diagnosis would be:

A.   Blood culture                                                                            B.    Splenic puncture

C.   Liver biopsy                                                                              D.    Bone marrow aspiration

Ans. D  (Kumar and Clark 4th ed., p  426-427)

The girl has developed acute leukaemia and hence bone marrow aspiration will confirm the diagnosis. The points in favour of leukaemia are, short history, TLC 30,000/cumm, petechiae (thrombocytopenia), mouth ulcer, anaemia, fever and hepatosplenomegaly.

99.    Consider the following modes of transmission:

1.   Kissing                                                                                       2.     Mosquito bite

3.   Transplacental                                                                         4.     Needlestick injury

         Those of HIV infection would include:

A.   2 and 4                                                                                      B.    1 and 3

C.   2 and 3                                                                                      D.    3 and 4

Ans. D  (Harrison 16th ed., p 1079)

The various modes of transmission of HIV are sexual, through blood and blood products and maternal-foetal/infant transmission.

Transplacental transmission is very important mode of transmission in developing countries. Virus can be transmitted as early as 1st or 2nd trimester of pregnancy. However maternal transmission to the foetus occurs most commonly in perinatal period. Treatment of HIV positive patients during pregnancy has significantly reduced the foetal infection.

Needle stick injury (mostly while recapping) is responsible for HIV transmission in health care workers. The risk of HIV transmission is 0.3%.

In saliva the titre of HIV is very low and there is no evidence of transmission of HIV by kissing.

Mosquito or any other vector does not transmit HIV.

100. Which of the following are true of management of high grade lymphoma?

1.   90% patients require chemotherapy

2.   Stage I is uncommon

3.   Prognosis is worse in younger patients

4.   A combination of cyclophosphamide, adriamycin, vincristine and prednisolone is most effective

         Select the correct answer using the codes given below:

Codes:

A.   2, 3 and 4                                                                                  B.    1, 3 and 4

C.   1, 2 and 4                                                                                  D.    1, 2 and 3

Ans. B 

Patients with intermediate and high-grade lymphoma are occasionally treated with irradiation for localized disease, but the mainstay of therapy is combination chemotherapy. The traditional treatment regimen has been cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP).

For patients with high risk disease like:

–   Age over 60 years.

–   Elevated serum LDH level.

–   Advanced stage disease (stage III and IV) and poor performance status should be treated initially with autologous stem cell transplantation.

Remember the following important points about non Hodgkin’s lymphoma:

1.  For relapse following initial chemotherapy treatment of choice is high dose chemotherapy with autologous stem cell transplantation.

2.  High-grade lymphoma includes immunoblastic, lymphoblastic, true histiocytic, small non-cleaved Burkitt’s and non-Burkitt lymphoma.

3.  In intermediate grades beside follicular large cell variety all diffuse type are included like diffuse small-cleaved cell, diffuse large cells and diffuse mixed cell variety.

4.  In Burkitt’s lymphoma characteristic cytogenetic abnormality is translocation between long arms of chromosomes 8 and 14

5.  Diagnosis of lymphoma is made by tissue biopsy.

101. The extent of muscle damage by a bullet depends primarily on the:

A.   Size                                                                                             B.    Velocity

C.   Shape                                                                                         D.    Weight

Ans. B  (Bailey and Love 23rd ed., p 281; 22nd ed., p 21; 24th ed., p 292-293; Reddy 22nd ed., p 171-172)

Tissue damage produced by high velocity bullets is disproportionaltey greater than that produced by bullet of ordinary muzzle velocity.

A bullet’s ability to wound is directly related to its kinetic energy [E=1/2 m (V22-V12)] at the moment of impact because kinetic energy increases in direct proportion to weight (mass) of the bullets and square of its velocity.  A bullet travelling at twice the speed of a second bullet having equal weight and similar shape possesses four times much energy or wounding power.

–   Hydrostatic forces cause excessive degree of destruction due to explosive displacement of liquid in all directions.

–   Greater the tissue density, greater is the amount of energy discharged by bullet passing through it.

102. Consider the following statements:

         Post-operative synergistic gangrene:

1.   Can occur as a complication of colostomy

2.   Can occur as a complication of drainage of empyema thoracis

3.   Needs hyperbaric oxygen therapy

         Of these statements:

A.   1 and 2 are correct                                                                  B.    1 and 3 are correct

C.   2 and 3 are correct                                                                  D.    1, 2 and 3 are correct

Ans. D  (Schwartz Principles of Surgery 6th ed., p 149)

Bacterial synergistic gangrene can occur as a complication of colostomy and drainage of empyema thoracis. Most of them are caused by mixed aerobic and anaerobic gram-negative and gram-positive bacteria. Clostridium species are the most common. The use of hyperbaric oxygen is a bit controversial. It inhibits the production of alpha toxin by clostridium. Its use in nonclostridial infections is controversial. Hyperbaric oxygen should not be used before surgical debridement.

103. In which of the following abscesses is drainage carried out without waiting for fluctuations to appear?

1.   Scalp abscess                                                                           2.     Parotid abscess

3.   Ischiorectal abscess                                                                4.     Inguinal abscess

         Select the correct answer using the codes given below:

Codes:

A.   1 and 2                                                                                      B.    2 and 3

C.   3 and 4                                                                                      D.    1 and 4

Ans. B  (Sabiston Textbook of Surgery 16th ed., p 984)

Parotid abscess and ischiorectal abscess must be drained as early as possible. Parotid abscess may involve facial nerve and cause facial paralysis.

Ischiorectal abscess are often deep seated and fluctuation appears late. Neglected abscess may lead to devastating, necrotizing infection of the perineum that can spread rapidly and become fatal.

104. A 56-year old lady is found to have a hard, nodular, painless swelling in the thyroid region. Diagnosis in this case is best established by:

A.   Ultrasound scan                                                                       B.    FNAC

C.   CT scan                                                                                     D.    Radioactive iodine scan

Ans. B  (Bailey and Love 24th ed., p 785)

Fine Needle Aspiration Cytology (FNAC) has become established, as investigation of choice is discrete thyroid swelling.

Remember the following important points about FNAC:

1.  FNAC cannot distinguish between follicular adenoma and follicular carcinoma, as this distinction is dependent not on cytology but on histological criteria, which include capsular and vascular invasion.

2.  There are very few false positives with respect to malignancy but there is a definite false negative rate with respect to both benign and malignant neoplasms.

3.  FNAC is less reliable in cystic than in solid swelling.

4.  Relatively few cysts are permanently abolished by one or more aspirations and because of the risk of malignancy, recurrent cyst should be removed.          

105. A simple equation to estimate the maximum allowable blood loss is:

         Allowable blood loss = Estimated blood volume × change in haematocrit × (3 – the average haematocrit).

         A patient whose estimated blood volume is 5 litres, has an initial haematocrit of 42%. His surgeon assumes that he can tolerate an haematocrit of 35%. How much blood volume can be lost before blood needs to be transfused?

A.   500 ml                                                                                       B.    800 ml

C.   900 ml                                                                                       D.    1000 ml

Ans. C  (Miller Anaesthesia 5th ed., 1652)

We have not come across the mentioned formula for allowable blood loss in any standard textbook and besides this the formula seems to be wrong. Allowable blood loss is calculated for autologous transfusion. The formula for calculation of allowable blood loss is:

V =

V is allowable blood loss and EBV is estimated blood volume.

Hence V =   = 909.09 ml.

106. After closure of a perforated duodenal ulcer, a 50-year old man has been maintained on gastric suction for seven days and has been receiving 5% dextrose in water, normal saline and vitamins as intravenous therapy. The average daily volume of gastric aspirate is 1500 ml/day. The patient has developed adynamic ileus and is extremely weak and lethargic. The most likely abnormality is:

A.   Metabolic acidosis                                                                  B.    Low serum magnesium level

C.   Low serum sodium level                                                        D.    Hypokalaemic alkalosis

Ans. D  (Bailey and Love 24th ed., p 1201)

Adynamic obstruction (paralytic ileus), weakness and lethargy following gastric aspirate by gastric suction for 7 days following perforated duodenal ulcer closure suggest hypokalaemia.

Remember the following important points about adynamic obstruction (paralytic ileus):

1.  It is a state in which there is failure of transmission of peristaltic waves occurring secondary to neuromuscular failure.

2.  Resultant stasis leads to accumulation of fluid and gas within the bowel with associated distention, vomiting, absence of bowel sounds and absolute constipation.

3.  Uraemia and hypokalaemia are the commonest contributory factors.

4.  Post-operative paralytic ileus is self-limiting with a variable duration of 24-72 hours after any abdominal operation.

5.  Post-operative ileus may be prolonged in presence of hypoproteinaemia or metabolic abnormality.

6.  Intra-abdominal sepsis may give rise to localized/generalized ileus.

7.  Reflex ileus may occur following fractures of the spine or ribs, retroperitoneal haemorrhage or even the application of a plaster jacket.

Essence of treatment is prevention with the use of nasogastric suction and restriction of oral intake until bowel sounds and the passage of flatus return.  Electrolyte balance must be maintained.

Specific treatment is directed towards cause:

l   Remove the primary cause.

l   Gastrointestinal distension must be relieved by decompression.

l   Maintenance of fluid and electrolyte balance.

l   No place for routine use of peristaltic stimulants.

l   Rarely Catchpole regime (neostigmine) may be used in resistant cases.

If paralytic ileus is prolonged and threatens life, a laparotomy should be considered to exclude a hidden cause and facilitate bowel decompression.

107. Two hours after subtotal thyroidectomy for thyrotoxicosis, a young woman rapidly becomes agitated and complains of increasing difficulty in breathing. Her pulse rate rises and central cyanosis is noticed. On examination, her neck is found to be tensely swollen beneath the stitches. The most appropriate management in the case would be:

A.   Intranasal oxygen

B.   Passing an endotracheal tube in the ward

C.   Removing sutures from all layers in the ward

D.   Immediate transfer of the patient to the operation theatre for tracheostomy

Ans. C  (Bailey and Love 24th ed., p 796)

2 hours after sub-total thyroidectomy, young women with agitation and increasing difficulty in breathing, increasing pulse rate and central cyanosis suggests post-operative airway obstruction. Tensely swollen neck beneath the stitches indicate tension haematoma, which, is most important cause of laryngeal oedema. Laryngeal oedema in most cases cause respiratory obstruction.

Treatment of tension haematoma is to open the wound in the ward to relieve tension before taking the patient to theatre to evacuate the haematoma and to tie off a bleeding vessel.

If releasing the tension haematoma does not immediately relieve airway obstruction, the trachea should be intubated at once. Endotracheal tube can be left in place for several days; steroids are given to reduce oedema and tracheostomy is rarely necessary.

Remember the following important points about postoperative complications of thyroidectomy:

l   Haemorrhage: Tension haematoma is usually due to slippage of a ligature on the superior thyroid artery, occasionally haemorrhage from thyroid remnant or a thyroid vein may be responsible.

l   Respiratory obstruction: Most cases of respiratory obstruction are due to laryngeal oedema. The most important cause of laryngeal oedema is a tension haematoma. Unilateral or bilateral recurrent nerve paralysis will not cause immediate postoperative respiratory obstruction unless laryngeal oedema is also present.

l   Recurrent laryngeal nerve paralysis: May be unilateral or bilateral, transient or permanent. Transient paralysis occurs in about 3 percent of nerves at risk and recovers in 3 weeks to 3 months.

l   Thyroid insufficiency: Usually occurs within 2 years. Rare after surgery for a thyroid adenoma because there is no autoimmune disease.

l   Parathyroid insufficiency: It occurs due to removal of parathyroid glands or infarction through damage to the parathyroid end artery. Often both factors occur together. Vascular injury is far more important than inadverent removal. Most cases present 2-5 days after operation but rarely delayed for 2-3 weeks or patient with marked hypercalcemia is asymptomatic.

l   Thyrotoxic crisis (storm): Is an acute exacerbation of hyperthyroidism. It occurs if patient has been inadequately prepared for thyroidectomy and is now extremely rare.

Very rarely, a thyrotoxic patient presents in a crisis and this may follow an unrelated operation.

Symptomatic and supportive treatment is for dehydration, hyperpyrexia and restlessness. This requires administration of intravenous fluids, cooling the patients with ice packs, administration of oxygen, diuretics for cardiac failure, digoxin for uncontrolled atrial fibrillation, sedation and intravenous hydrocortisone.

Specific treatment is by:

l   Carbimazole: 10-20 mg 6 hourly.

l   Lugol’s iodine: 10 drops 8 hourly by mouth.

l   Sodium iodide: 1 gm IV.

l   Propranolol 40 mg 6 hourly orally will block adverse beta-adrenergic effects.

Other complications are wound infection, hypertrophic/keloid scar, stitch granuloma.

108. An inflammatory carcinoma of the breast, measuring 4 cm in diameter, is staged as:

A.   T1                                                                                                                                                B.    T2

C.   T3                                                                                                                                                D.    T4

Ans. D  (ASI Textbook of Surgery p 1056; Schwartz Principles of Surgery 6th ed., p 541)

The carcinoma is staged as T4d.

Abridged TNM classification of carcinoma of breast:

Tx: Primary tumour cannot be assessed.

T0: No evidence of primary tumour.

Tis: Carcinoma in situ:

–   Clinical Paget’s disease of nipple with no tumour mass.

–   Pathological intraductal carcinoma.

–   Lobular carcinoma in situ.

–   Paget’s disease with no invasive component.

T1: Tumour 2 cm or less in greatest dimension.

T2: 2-5 cm size tumour in greatest dimension.

T3: Tumour more than 5 cm in greatest dimension.

T4: Tumour of any size with direct extension to chest wall or skin. Chest wall includes ribs, intercostal muscles and serratus anterior muscles but not pectoral muscles.

T4a: Extension to chest wall.

T4b: Oedema (including peau d’orange):

–   Ulceration of skin of the breast.

–   Satellite skin nodule confined to same breast.

T4c: Both 4a and 4b above.

T4d: Inflammatory carcinoma.

109. The best results of tamoxifen therapy following modified radical mastectomy are obtained if the tumour is (ER: Estrogen Receptor; PR: Progesterone Receptor):

A.   ER positive and PR positive                                                  B.    ER negative and PR positive

C.   ER positive and PR negative                                                 D.    ER negative and PR negative

Ans. A  (Schwartz Principles of Surgery 6th ed., p 583)

Antifertility drug, tamoxifen initiates regression of breast cancer. Antitumour activity is correlated closely with reactivity of ER and/or PR.

Antioestrogens block the uptake of oestrogen by the target tissue following cytosol binding to ER.

–   Decreased responsiveness at one dose level may be reversed by escalation of dose.

–   Advantage of tamoxifen over chemotherapy is the absence of toxicity and profound side effects.

–   Flare of bone pain with hypercalcaemia at initiation of therapy is seen which is usually short lived.

–   With therapeutic oestrogen pain, nausea, vomiting and fluid retention is seen.

110. The most important prognostic factor in a patient with carcinoma breast is:

A.   Age of the patient                                                                    B.    Size of the primary tumour

C.   Nodal status                                                                             D.    Hormone receptor status

Ans. C  (Bailey and Love 24th ed., p 839)

Best indicators of likely prognosis in breast cancer are tumour size and lymph node status. However it is to be kept in mind that some large tumours will remain confined to the breast for decades whereas some very small tumours are incurable at diagnosis.

So best indicator for prognosis is lymph node status.

To define which tumour will behave aggressively, and thus require early systemic treatment, a host of prognostic factors are described which include:

–   Histological grade of the tumour.

–   Hormone receptor status.

–   Measure of tumour proliferation such as S phase fraction and thymidine-labeling index.

–   Growth factor analysis.

–   Oncogenes or oncogene product measurements.

111. A 20-year old male patient has been brought to the casualty in a state of shock after a scooter accident. Plain X-ray shows fracture of left lower ribs with bruising of overlying skin and rigidity in left upper abdominal quadrant. The most likely diagnosis is:

A.   Injury to left kidney                                                                B.    Rupture of spleen

C.   Perforation of stomach                                                          D.    Injury to left lobe of liver

Ans. B  (Bailey and Love 24th ed., p 1087)

After scooter accident, patient is in state of shock with bruising of overlying skin and rigidity of left upper abdominal quadrant with X-ray finding of fracture of left lower ribs favors the diagnosis of internal hemorrhage due to rupture of spleen.

Other findings in this type of presentation are:

l   Kehr’s sign: Pain referred to left shoulder.

l   There may be hyperaesthesia in area demonstrated 15 minutes after elevation of foot of the bed.

l   Shifting dullness may be present in the flanks and on rectal examination fullness in the pelvis is present.

Other types of presentation mentioned are:

l   The patient succumbs rapidly from massive haemorrhage. It rarely occurs in the normal spleen but is a reminder that a slipped pedicle suture can lead to rapid exsanguination.

l   In delayed case, after the initial signs have passed off and the concern about a serious intra-abdominal bleed has been postponed, late rupture can occur. Such cases should now be rare as scanning should delineate such patients and a haematoma around spleen should be an indication for either laparotomy or, at the minimum, close observation.

–   Delayed type of rupture (following trivial injury) is also very common and the patient is admitted with a perisplenic haematoma.

–   Malaria is most common cause of spontaneous splenic rupture in tropical countries.

112. A patient presents with jaundice, right upper quadrant pain, chills with high fever, hypotension and mental confusion. The most likely diagnosis is:

A.   Gallstone pancreatitis                                                             B.    Hepatitis

C.   Acute suppurative cholangitis                                               D.    Amoebic liver abscess

Ans. C  (Bailey and Love 24th ed., p 1109)

Pain, jaundice and fever with rigor is known as Charcot’s triad. It is a feature of acute cholangitis seen in CBD stones.

Cholangitis is a complication of CBD stone. The features are due to inflammation, which usually requires partial obstruction to bile flow. Bacteria can be isolated from bile in about 75% of cases.

Nonsuppurative cholangitis respond better to antibiotics. Suppurative cholangitis is however a dangerous complication and may even lead to septic shock. Immediate drainage of infected bile by endoscopy or surgery is required with good coverage of antibiotics.

113. Serious complications in pancreatic pseudocyst include all of the following except:

A.   Intracystic haemorrhage                                                        B.    Secondary infection

C.   Calcification in the cyst wall                                                 D.    Rupture of the cyst

Ans. C  (Schwartz Principles of Surgery 6th ed., p 1419)

The most feared complications of pseudocyst are haemorrhage, rupture and infection.

Other complications of pseudocyst of pancreas include obstruction of the gastrointestinal tract (duodenum and stomach) and common bile duct obstruction.

l   Mature asymptotic cysts, less than 5 cm in diameter, probably require no treatment.

l   Elective surgery is to be delayed for 4-6 weeks till pseudocyst is mature.

l   Three types of surgical procedures used to treat pseudocyst are – resection, external drainage and internal drainage.

Pseudocyst of pancreas occurs usually as a complication of pancreatitis although some may occur even after trauma.

114. A 40-year old male was brought to the hospital with acute pain in the upper abdomen. Patient was in shock with feeble pulse and tachycardia. There was tenderness in the epigastrium. There was no blood in the gastric aspirate and the patient felt better after aspiration. X-ray abdomen showed no free gas under the diaphragm. Investigations revealed  TLC 13500, serum bilirubin 2.0 mg and serum amylase 800 IU. The most likely diagnosis is:

A.   Acute cholecystitis                                                                  B.    Acute pancreatitis

C.   Acute peritonitis                                                                       D.    Acute appendicitis

Ans. B  (Harrison 16th ed., p 1897)

The patient is suffering from acute pancreatitis. The main point in diagnosis is the serum amylase level. In normal condition the value is 60-180 IU/L and three to four fold rise is seen in acute pancreatitis. In this patient the value is 800 IU.

The other causes of raised amylase level are to be kept in mind and excluded. The important causes are:

a.  Intestinal obstruction with gangrene: No air fluid level in X-ray in the patient.

b.  Perforated duodenal ulcer: No blood in gastric aspirate or gas under diaghragm in X-ray.

c.  Cholecystitis: No history or examination finding suggestive of cholecystitis and X-ray does not show any stone though the incidence is less.

d.  Acute peritonitis: No history or examination finding in this patient. Tenderness present only in epigastrium.

Acute appendicitis is not a cause of raised amylase.

For treatment of pancreatitis see Q 45 paper 1 UPSC 1999.

For Ranson and Imrie criteria see Q 46 paper 1 UPSC 2003.

115. All of the following are features of direct inguinal hernia except:

A.   Rarely descends into the scrotum                                        B.    Strangulation rarely occurs

C.   Passes through the internal ring                                            D.    Contents may be bladder

Ans. C  (Bailey and Love 24th ed., p 1278)

l   In 35% adult males inguinal hernia is direct though most common type is indirect type of inguinal hernia.

l   Direct hernias do not often attain a large size or descend into the scrotum.

l   As the neck of the sac is wide, direct inguinal hernia does not often strangulate.

l   A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal.

Remember the following important points about direct inguinal hernia:

l   Women practically never develop a direct inguinal hernia.

l   Predisposing factors:

–   Smoking.

–   Occupation that involves straining and heavy lifting.

–   Damage to ilio-inguinal nerve (previous appendicectomy) due to resulting weakness of the conjoined tendon.

l   Though direct hernia does not often strangulate, as neck of the sac is wide ‘funicular direct hernia’ (syn. prevesical hernia) is a narrow necked hernia with prevesical fat and a portion of the bladder that protrudes through small oval defect in the medial part of the conjoined muscle just above the pubic tubercle.  Unless there are definite contraindications operation should always be advised.

116. Abnormal obturator artery creates a dangerous situation in the repair of:

A.   Direct inguinal hernia                                                              B.    Indirect inguinal hernia

C.   Femoral hernia                                                                         D.    Obturator hernia

Ans. C  (Gray’s Anatomy 38th ed., p 1560)

Abnormal obturator artery creates a dangerous situation in repair of femoral hernia. Obturator artery is a branch of anterior trunk of internal iliac artery.

In 20-30% of subjects an enlarged pubic branch of the inferior epigastric artery, which descends almost vertically to the obturator foramen, replaces the obturator artery.  Such an obturator artery is usually near the external iliac vein lateral to femoral ring.

–   Sometimes it curves along the edge of the lacunar part of the inguinal ligament, partly encircling the femoral ring.

117. Which one of the following physical signs/laboratory aids is helpful in the diagnosis of bowel strangulation?

A.   Marked abdominal distension                                              B.    Persistent local tenderness

C.   Profuse voming                                                                        D.    Multiple air fluid levels on X-ray

Ans. B  (Bailey and Love 23rd ed., p 1061; Schwartz Principles of Surgery 6th ed., p 1029)

Steady severe pain without quiescent periods is usually indicative of strangulation.

In the 23rd edition of Bailey & Love it is written that in nonstrangulated obstruction of intestine there may be an area of localized tenderness at the site of obstruction; in strangulation there is always localized tenderness associated with rigidity/rebound tenderness.

Rest of the three conditions may be present in both obstruction as well as strangulation. The presence of shock indicates ischaemia of bowel. In strangulation pain is never completely absent.

Remember the following important points about intestinal obstruction and strangulation:

–   Four cardinal symptoms and signs of intestinal obstruction are crampy abdominal pain, vomiting, obstipation and abdominal distention.  The finding of localized tenderness, fever, tachycardia and leuocytosis are supportive of, but not diagnostic for strangulation.

–   Progressive distention, which may be marked in the presence of a competent ileocaecal valve, is the most dangerous aspect of colonic obstruction.  If the ileoacaecal valve is competent, then a closed-loop obstruction is present, with progressive distention and there is strong possibility of caecal perforation.

–   Mild to moderate dehydration, early in the course, with hemoconcentration and a decreased output of concentrated urine.

–   White blood count modestly elevated (<15,000 cell/ml) but elevation above this is suggestive of strangulation. Very high counts (< 40,000 cell/ml) are suggestive of primary mesenteric vascular disease.

–   Other nonspecific tests used to differentiate obstruction and strangulation include serum amylase, phosphorus and lactic acid.

–   In abdominal films with an upright chest radiograph, gas fluid levels are highly suggestive of intestinal obstruction, but are also seen in extreme aerophagia, gastroenteritis, severe constipation, sprue and infants.

118. A 35-year old woman complains of attacks of breathlessness, cyanosis and flushing. Apart from occasional diarrhea she has no abdominal symptoms. Abdominal examination reveals an enlarged nodular liver. If laparotomy is done, we could expect to find:

A.   An ovarian tumour                                                                 B.    A multicentric hepatoma

C.   An appendicular carcinoid                                                    D.    Crohn’s disease

Ans. C  (Harrison 16th ed., p 2222; Bailey and Love 24th ed., p 1217-1218)

History of breathlessness, cyanosis and flushing points towards carcinoid syndrome.

Enlarged nodular liver means hepatic metastasis, which is essential to produce carcinoid syndrome.

Appendicular carcinoids are detected in 1 in every 200-300 appendicectomies. It is one of the commonest sites for carcinoid tumours.

Considering these facts the logical conclusion is that in laparotomy appendicular carcinoid will be found.

Carcinoid tumours are commonly seen in appendix, small intestine, lungs, stomach etc.

Flushing, diarrhoea, wheezing, pellagra like skin lesions are the common features.

Carcinoid tumours secrete large amount of serotonin.

Treatment is with somatostatin analogues like octreotide, lanreotide etc. Surgery is done whenever possible to remove the tumours.

119. The operation of choice for annular pancreas is:

A.   Division of annular ring                                                          B.    Gastrojejunostomy

C.   Duodenojejunostomy                                                            D.    Pancreaticoduodenectomy

Ans. C  (Bailey and Love 24th ed., p 1120; Schwartz Principles of Surgery 6th ed., p 1406)

The treatment of annular pancreas is duodenojejunostomy or gastrojejunostomy either of which bypasses the obstruction.

According to Bailey and Love duodenoduodenostomy or duodenojejunostomy are usual operation.

Obstructing pancreatic ring must not be simply divided.  Since this may not relieve the obstruction and pancreatic fistula may result.

Annular pancreas is formed by a thin band of normal pancreas tissue that completely encircles the second portion of duodenum and is continuous with head of pancreas anteriorly and posteriorly.  40% patients have associated duodenal stenosis or atresia.

Symptoms of duodenal obstruction (gastric distention and vomiting) occur in about one third of cases in the first week of life and about one half of cases in the first year.  Rest are asymptomatic until adulthood, when abdominal pain, nausea and vomiting may occur.

120. A 24-year old male, who has been having fever for 15 days, starts having acute pain and distension of abdomen. Abdominal examination reveals generalised tenderness with guarding. The most likely diagnosis is:

A.   Acute appendicitis                                                                   B.    Acute pancreatitis

C.   Enteric perforation                                                                  D.    Duodenal ulcer perforation

Ans. C  (Harrison 16th ed., p 899)

The clinical picture described is classical of enteric perforation and peritonitis.

In enteric fever ulcers occur in intestine, which may perforate if not treated properly. This complication is seen in third or fourth week of fever. It is a life threatening complication and urgent medical and surgical intervention is required.

GIT haemorrhage is another life threatening complication of enteric fever that occurs in third or fourth week of fever.

In acute appendicitis and acute pancreatitis abdominal pain is the main feature rather than fever of 15 days duration.

In DU perforation fever is absent.