Datasets:

ridhomhd

/

MedMCQA-filtered

like 0

43da65ef-65a8-4c89-a08d-73c92e80828b

False about Charcot's joint in diabetes mellitus is:

Limitation of movements with bracing

Ahrodesis

Total ankle replacement

Ahrocentesis

multi

Treatment of Charcot's ahropathy- limitation of joint movements by bracing or casting, joint debridement (ahrocentesis) and fusion of joint (ahrodesis). Please remember that replacement is advocated now with advances in treatment but still it will be the least preferred treatment for ankle it can be carried for knee.

Orthopaedics

Joint Disorders

c8bed643-6f04-43f0-8bfc-b86552d35ce8

Which of the following is not a cause of hypermetropia: September 2009

Sho axial length of the eyeball

Flat cornea

Increased refractive index of the coex of lens

Anterior dislocation of the lens

multi

Ans. D: Anterior dislocation of the lens Factors responsible for hypermetropia: Sho axial length of the eyeball Curvature hypermetropia commonly occurs as a factor in astigmatism (corneal plana) Index hypermetropia accounts for the hypermetropia of old age due to increased refractive index of the coex of the lens relative to the nucleus so that overall refractive power of the lens decreases. It may be associated with diabetes, tumors, microphthalmia (a growth dysfunction during fetus development) and fovea hypoplasia, a condition that affects the blood vessels in the retina. While these conditions may result in hypermetropia, one of the most commonly cited causes of farsightedness is considered to be aging.

Ophthalmology

a2212b25-0439-44b0-b20b-ce85898138b8

Congenital hea disease is most likely in the newborn of mothers suffering from all except

Systemic lupus erythematosus

Rheumatoid ahritis

Diabetes in pregnancy

Congenital hea disease of the mother

multi

Effects of SLE on pregnancy : Risks of lupus rash,anemia, leukopenia, thromboctopenia and renal failure are increased. They are increased risks of First trimester miscarriage,lupus nephritis, reccurent DVT,PIH, Prematurity,IUGR and stillbihs. Neonatal lupus syndrome is due to crossing of maternal lupus antibodies(anti-RO or anti-La) to the fetus causing Hemolytic anemia,leukemia and thrombocytopenia. Isolated congenital hea block is pesent in about one-third of cases. Effect of Diabetes on pregnancy: Congenital Malformation (6-10%) is related to the severity of diabetes affeting organogenesis, in the firs trimester(both type 1 and tye 2) Effects of Congenital hea disease of mother on Pregnancy Likely to cause hea disease in newborn accounts for 3-13% Reference DC.Duttas textook of OBG ,9th edition

Gynaecology & Obstetrics

Medical, surgical and gynaecological illness complicating pregnancy

e8565503-0dee-4c8d-9bf3-ca2c6decdb95

Cataract is cases of diabetes mellitus is due to accumulation of ?

Glycated crytallins

Calcified crystallins

Glycated fibrillins

Calcified fibrillins

multi

Ans. is 'a' i.e., Glycated crytallins Diabetic cataract Senile cataract tends to develop at an earlier age and more rapidly than usual in diabetic subjects. The lenses of an adult diabetic are said to be in the same condition as a non-diabetic who is 15 years older. In diabetic adults, coin- pared to non-diabetics, cataracts are more prevalent, are dependent on the duration of diabetes and progress more rapidly. The mechanisms are believed to be glycation, carbamylation of crystallins and increased oxidative damage. True diabetic cataract is a rare condition occurring typi- cally in young people in whom the diabetes is so acute as to disturb grossly the water balance of the body. A large number of fluid vacuoles appear under the anterior -td posterior pas of the capsule, initially manifesting as myopia and then producing a diffuse opacity which at this stage is reversible. The lens then rapidly becomes cataractous, with dense, white subcapsular opacities in the anterior and posterior coex resembling a snowstorm- 'snowflake' cataract. Fine, needle-shaped polychromatic coical opacities may also form. With appropriate treatment to control hyperglycaemia, the rapid progression to mature cataract may be arrested at this stage.

Ophthalmology

c3199e7e-3cd5-4dbe-8ba6-48f7ce32ec47

The carpal tunnel syndrome can be caused by all, EXCEPT:

Hypothyroidism

Tuberculosis

Pregnancy

Acromegaly

multi

Many systemic conditions are strongly associated with carpal tunnel syndrome (CTS). These conditions may directly or indirectly affect microcirculation, pressure thresholds for nerve conduction, nerve cell body synthesis, and axon transpo or interstitial fluid pressures. Peurbations in the endocrine system, as observed in individuals withdiabetes, acromegaly and hypothyroidism and in women who are pregnant, are linked to CTS. Conditions affecting metabolism (eg, alcoholism, renal failure with hemodialysis, mucopolysaccharidoses) also are associated with CTS.

Surgery

6370d224-85d3-4d59-bfa1-0549735dd448

Child with Type I Diabetes. What is the advised time for fundus examinations from the time of diagnosis?

After 5 years

After 2 years

After 10 years

At the time of diagnosis

single

Screening for diabetic retinopathy To prevent visual loss occurring from diabetic retinopathy a periodic follow-up is very impoant for a timely intervention. The recommendations for periodic fundus examination are as follows : First examination, 5 years after diagnosis of type 1 DM and at the time of diagnosis in type 2 DM. Every year, till there is no diabetic retinopathy or there is mild NPDR. Every 6 months, in moderate NPDR. Every 3 months, in severe NPDR Every 2 months, in PDR with no high-risk characteristics. Ref;A.K.Khurana; 6th edition; Page no: 280

Ophthalmology

Vitreous and retina

a8a2f5fe-e22a-4ea7-9292-df1dc87f615d

Which of the following is not an indication of amniocentesis for chromosomal anomaly detection?

Gestation diabetes

Previous Down's child

Maternal age more than 35

Parents with chromosomal anomaly

single

Ans, is a, i.e. Gestation diabetesRef. Dutta Obs. 7/e, p 647; Fernando Arias 3/e, p 46, 47; COGDT 10/e, p 107, Williams Obs. 23/e, p 299, 300Amniocentesis or chorionic villi sampling should be offered to the following class of patients:-Singleton pregnancy and maternal age 35 years or above.-Twin pregnancy at age over 31 years of pregnancy.-Previous chromosomally abnormal child.-Three or more spontaneous abortions.-Patient or husband with chromosome anomaly.-Family history of chromosome anomaly.-Possible female carrier of X-linked disease.-Metabolic disease risk (because of previous experience or family history).-NTD risk (because of previous experience or family history).-Positive second-trimester maternal serum screen or major fetal structural defect identified by USG.

Gynaecology & Obstetrics

Diagnosis in Obstetrics

63d9496b-f572-4dd7-8863-fda99f500dd1

Edema feet is not a feature of:

Conn syndrome

Hypothyroid

CHF

Nephrotic syndrome

single

Ans. A. Conn syndromea. In Conn syndrome there is profound hypokalemia that leads to nephrogenic diabetes insipidus.b. Although excess of sodium is reabsorbed due to high amount aldosterone, but excess of water is lost. Hence edema feet is not a feature in Conn syndrome.

Medicine

Endocrinology

d25c3d6f-ee87-4a67-8084-a2c0f9d65da2

Ulcers in diabetes are precipitated by all EXCEPT: September 2012

Microangiopathic changes in blood vessels

Neuropathy

Trophic ulcers

Macroangiopathy

multi

Ans. A i.e. Microangiopathic changes in blood vessels

Surgery

75706930-7ea0-4c58-b8db-1df8e976221d

A 32-year-old woman is evaluated in the clinic for symptoms of polyuria and polydipsia. She has no significant past medical history and her only medication is the oral contraceptive pill.Her physical examination is entirely normal. Urine and serum biochemistry investigations are suggestive of central diabetes insipidus (DI). Which of the following is the most likely finding on magnetic resonance imaging (MRT) of the brain?

hypothalamic tumor

hyperintense signals in the cerebral cortex

agenesis of the corpus callosum

lack of hyperintense signals from the posterior pituitary

multi

Because DI is usually caused by destruction, or agenesis, of the posterior pituitary, its normal signaling is lost. Pituitary DI can also result from trauma, tumors (both primary and secondary), granulomas, infections, inflammatory diseases, chemical toxins, congenital malformations, and genetic disorders.Depending on the cause, the MRI may demonstrate other associated findings.

Medicine

Endocrinology

7ba5deeb-89f2-4339-bca7-854383f3e45d

A 50-year-old male with 2 diabetes mellitus is found to have 24-hour urinary albumin of 250 mg. Which of the following drugs may be used to retard the progression of the renal disease -

Hydrochlorthiazide

Enalapril

Amiloride

Aspirin

single

Medicine

a43e96de-c7cb-4446-87b0-bcec3cd9d378

Which of the following drugs is to be immediately stopped in a patient of diabetes with HTN and serum creatinine level of 5.6 mg?

Metformin

Insulin

Metoprolol

Linagliptin

single

ANS. AMetformin is contraindicated in patients with high creatinine because of the risk of lactic acidosis.# Specific side effects of OHAMetformin1. GI symptoms2. B12 deficiency3. Lactic acidosis (especially in patients with high creatinine, liver failure, alcoholism, cardiorespiratory insufficiency)Piogiitazone1. Unsafe in Renal failure, Liver failure, cardiac failure2. Increased risk of bladder cancer3. OsteoporosisDPP-4 inhibitors1. Upper respiratory tract infection2. Renal toxicity (Vildagliptin is hepatotoxic)(Safest DPP-4 inhibitor in renal failure is linagliptan)(asked in Nov AIIMS 2016 and May 2017)SGLT2 inhibitors1. UTI2. Risk of bladder cancer

Pharmacology

Endocrinology

5ade7921-5b2d-4880-ade4-c2032830a9f4

Absolute Contraindication for the Use of OCPs is:

Thromboembolism

Hypeension

Diabetes

Epilepsy

single

Absolute contraindications of OCP'S: - C - Cancers - L - Liver diseases - U - Uterine bleeding - T - Thromboembolism - C - Cardiovascular diseases - H - Hyperlipidemia - Preganancy Also remember, Long-standing or complicated diabetes (with microvascular complications) is absolute contraindication. Grade I hypeension is relative contraindication and Grade II is absolute. Simultaneous use of some anti-epileptics is relatively contraindicated .

Social & Preventive Medicine

Natural Methods, Barrier Methods, IUDs, OCPs

68ec3585-8901-47f0-ac07-02990c89c9cd

All of the following skin changes are associated with Diabetes Mellitus except

Acanthosis Nigricans

Granuloma annulare

Necrobiosis lipiodica

Salmon patch

multi

Salmon patch is associated with "Sturge - Weber" syndrome.

Dental

ad32342f-b600-4732-bbf5-cd40523d5d6b

Which of the following drugs should NOT be used in the setting of severe hypeension in elderly on empirical basis?

Enalapril

Amlodipine

Chlohiazide

Prazosin

single

For the elderly, alpha blockers like prazosin can cause severe hypotension and 1st dose hypotension DOC for elderly with severe HTN - CCBs DOC for HTN with diabetes- ARBs or ACE inhibitors Ref:Tripati 8th edition

Pharmacology

Cardiovascular system

e6bcb907-98bb-4509-8c1e-2ce826c2975f

The triad of diabetes, gallstones and steatorrhoea is associated with which one of the following tumours?

Gastrinomas

Somatostationomas

VIPomas

Glucagonomas

multi

Medicine

a07fdb39-ea23-4b28-b06d-2e4ffe1d6a2e

Diabetes melitus is diagnosed if fasting blood glucose is ?

>100

>126

>110

>116

single

Criteria for the diagnosis of Diabetes mellitus : * Symptoms of diabetes plus random blood glucose concentration >= 11.1 mmol/L (200 mg/dL) or * Fasting plasma glucose >= 7.0 mm/L (126 mg/dL) or * Glycosylated haemoglobin >= 6.5% or * 2-hr plasma glucose >= 11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test. Normal fasting blood glucose : 70-110 mg/dL Reference : page 2401 Harrison's Principles of Internal Medicine 19th edition

Medicine

Endocrinology

23ce684b-1841-4777-97d7-6efa101ae951

A 50 years old male with 2 diabetes mellitus is found to have 24 hour urinary albumin of 250 mg. Which of the following drugs may be used to retard progression of renal disease -

Hydrochlohiazide

Enalapril

Amiloride

Aspirin

single

Ans is option 2 - Enalapril ACE inhibitors and ARB&;s are specifically indicated to reduce progression of renal disease. Ref Harrison 19 /2428

Medicine

Endocrinology

942f83f8-a546-4fe2-9853-930b73b515b1

A 47-year-old man with type II diabetes repos for his 6-month checkup. His doctor prescribes a daily 30-minute routine of walking at a brisk pace. During aerobic exercise, blood flow remains relatively constant to which of the following organs?

Brain

Hea

Kidneys

Skeletal muscle

single

Cerebral blood flow at rest is about 750 mL/min and remains unchanged during any grade of muscular exercise. During exercise, coronary blood flow is increased by four to five times with 100% O2 utilization. Renal blood flow is also decreased by 50-80% in severe exercise. During strenuous exercise muscle blood flow can increase up to 20 times, i.e. about 50-80 mL/ 100 g/min muscle tissue.

Physiology

Cardiovascular system

680bd402-d4fb-4398-997b-34f8248a73e3

A 56-year-old woman with diabetes, hypertension, and hyperlipidemia is found to have an A1C of 11 despite her best attempts at diet and faithfully taking her metformin and glyburide. The patient mentions that she has been unable to exercise much, partially due to severe fatigue and sleepiness in the daytime. On examination she is obese, has a full appearing posterior pharynx, clear lungs, a normal heart examination, and trace bilateral edema. Reflexes and skin are normal. Her TSH is 2.0 m/L (normal). The patient asks if there is anything else that can be done before adding another oral agent or switching to insulin. What is the best next step?

Educate the patient on sleep hygiene to ensure better rest and more energy.

Prescribe zolpidem as a sleep aid to help her sleep and increase her energy to exercise during the day.

Explore for possible depression as a contributor to the fatigue which is keeping her from exercising.

Arrange for a sleep study to check the patient for obstructive sleep apnea.

multi

Obstructive sleep apnea (OSA) that has gone untreated contributes to increased insulin resistance. This appears to have an additional effect even beyond the common cooccurrence of obesity as in this patient. Treatment of OSA can lead to improvement in glucose control. This patient is obese, has a crowded oropharynx on examination, and has daytime somnolence. Although overnight oxygen saturation monitor may be performed at home as screening, this patient is at high risk of complications of OSA should proceed directly to formal overnight polysomnography. Sleep hygiene is important for patients with sleep disturbance but is not likely to help in this patient with probable severe OSA. Similarly, sedative hypnotic agents such as zolpidem are widely prescribed for sleep but could exacerbate the OSA. Depression should always be explored but there are no clues beyond fatigue to suggest this diagnosis. Low vitamin D levels are generally asymptomatic unless the condition is severe and prolonged and would not affect sleep apnea or glucose control specifically.

Medicine

Endocrinology

797c702f-9803-4b31-b3c6-4b1b42d5cf72

Which of the following is not the criteria for diagnosis of Metabolic syndrome?

Hypeension

Central obesity

Hyperiglyceridemia

High LDL

single

Metabolic syndrome/Syndrome X: Central obesity: Waist circumference >102cm in males,>88cm in females. Hyperiglyceridemia: >150mg% Low HDL cholesterol: <40mg%I(male), <50mg% (female) Hypeension: >130/80 mmHg Fasting blood glucose >100 mg% / previously diagnosed type 2 diabetes. NOTE:Raised LDL is NOT a feature of Metabolic syndrome.

Medicine

NEET Jan 2020

a942906f-ed09-4b02-a88e-d246f207d122

29 year old female with history of Sjogren's syndrome presents with a 2 day episode of watery diarrhea 2 days ago. Physical examination is unremarkable. Because of her history, the physician decides to check her urine electrolytes. Urine chemistry: K = 31, Na = 100, Cl = 105. Her current diagnosis is?

Renal tubular acidosis

Hypochloremic Metabolic alkalosis

Malignant hypeension

Respiratory alkalosis

single

* The urine electrolytes are used to distinguish between A and diarrhea * UAG is an indirect measure of ammonium excretion * UAG = (Na + K) - Cl * UAG = ( 100 + 31 ) - 105 = 26 * A positive UAG suggest A because in the setting of diarrhea, ammonium chloride concentration in the urine would be high and the UAG would be negative. * A positive value suggests that the kidney is unable to adequately excrete ammonium, leading to a reduction in net acid excretion and thus metabolic acidosis. Hyperkalemia, acidemia is seen in type IV A Type IV A associated with Diabetes Mellitus

Medicine

Electrolyte Imbalance

86b330e6-2d86-4b03-8a93-003d3de4f8ae

Following are the factors for increased risk of wound infection EXCEPT

Malnutrition

Good blood supply

Metabolic diseases (diabetes, uraemia)

Immunosuppression

multi

Ans. (b) Good Blood Supply(Ref. Surgery Sixer 3rd Edition Page 33)Systemic Factors causing non healing of Wound:* Diabetes* Radiation* Extremes of age* Hypothermia* Hypoxemia* Hypocholesterolemia* Hyperglycemia (Even if transit)* Malnutrition* Vitamin C and A deficiency* Zinc and Iron deficiency* Drugs: Steroids and Doxorubicin* Jaundice, Uremia and Malignancy* Immunosuppressed State

Surgery

Miscellaneous

5a071f66-a8bd-4c19-a5cd-2d444485ab84

Hypoglycemic unawareness that occurs in diabetic patients when transferred from oral hypoglycemics to insulin, is due to :

Autonomic neuropathy

Insulin resistance

Lipodystrophy

Somogi phenomenon

single

Answer is A (Autonomic neuropathy): Hypoglycemic unawareness refers to a loss of warning symptoms that ale individuals to the presence of hypoglycemia and prompt them to eat and'abo the episode. Hypoglycemic unawareness can be attributed to two factors : Autonomic neuropathy Loss of catecholamine response to hypoglycemia : This means that patients with repeated attacks of hypoglycemia lose their capacity to release epinephrine and norepinephrine in response to hypoglycemia. (increase release of glucogon in response to hypoglycemia is lost very early in type I Diabetes Thus type I patients overeated with insulin may be unaware of critically low levels of blood glucose because of an adaptive blunting of their alarm systems owing to repeated episodes of hypoglycemia.

Medicine

d6ece7a6-6a6b-4086-9c6a-f8e09391bbe3

Renal transplantation is most commonly done in -

Chr. glomerulonephritis

Bilateral staghorn calculus

Horse shoe kidney

Oxalosis

single

Renal transplantation is the preferred treatment for many patients with end stage renal disease (ESRD), because it provides a better quality of life for them than dialysis. The most common causes of ESRD (in decreasing order) are: Diabetes mellitus Hypertension Glomerulonephritis

Surgery

f61d4dca-1b53-40f8-84be-1cb742d717b7

In children with type IDM when is ophthalmologic evaluation indicated

At the time of diagnosis

After 1 year

After 2 years

After 5 years

single

Ophthalmologic examination should be conducted once the child is >10 yr of age and has had diabetes for 3 -5 year. Annual follow up should suggest. Reference: OP Ghai,essential paediatrics,8 th edition, page no 546

Pediatrics

Endocrinology

9f0780b8-052e-4c1d-9d5a-3d8fbeba9efc

In Diabetes, What happens to RQ:

RQ always increases in Diabetes

RQ increases & on giving Insulin it again decreases

RQ always decreases in Diabetes

RQ decreases & on giving Insulin it again increases

single

Respiratory Quotient (RQ) Calculation of RQ of Glucose (carbohydrates): Oxidation of glucose in body: C6H1206 + 602 - 6C02 + 6H20 So, RQ = 6/6 = 1 RQ VALUES for different food components: Carbohydrates - 1 Proteins - 0.8 Fats - 0.74 Mixed diet - 0.85 Brain - 0.97 - 0.99 RQ TELLS US Type of macromolecules used in the body Conversion of one macromolecule to another FASTING / STARVATION - RQ decreases RQ in Diabetics - RQ decreases On giving insulin - RQ Increases

Biochemistry

Miscellaneous

e685f32f-17f9-4ee6-a9c8-058054cfdaf0

Which of the following agents is useful for the oral treatment ofboth pituitary as well as renal diabetes insipidus?

Vasopressin

Hydrochlohiazide

Chlorpropamide

Carbamazepine

multi

(Ref: KDT 6/e p577, 578) Thiazides are useful in the treatment of central as well as nephrogenic DI. Vasopressin, chlorpropamide and carbamazepine are useful only in central DI.

Anatomy

Other topics and Adverse effects

8b4e4e47-4da5-4700-8ab8-b41ac8ed2c3e

For diagnosis of diabetes mellitus, Fasting blood glucose level should be more than -

126 mg/dl

140 mg/dt

100 mg/dl

200 mg/dl

single

Ans. is 'a' i.e., 126 mg/di DIAGNOSTIC CRITERIA FOR DIABETES1) Symptoms of diabeticsplusrandom blood glucose concentration >200 mg/dl.(Random is defined as without regard to time since last meal)or2) Fasting plasma glucoseQ > (126 mg/dl)or3)Two hour plasma glucoseQ > (200mg/dl) during an oral GTTor4) A1C > 6.5% (Added in 18th/ep. 2969)o The random blood sugar level does not meet the criteria for diabetes where as fasting blood glucose far exceeds the required level.o The diagnosis of diabetes cannot be made only with fasting blood glucose > 126 mg/dL.o So the next best step is to either repeat the test or perform oral G..1. T.o Harrison further adds that in the absence of unequivocal hyperglycemia and acute metabolic decompensation these criterias should be confirmed by repeat testing on a different day.o Benedicts test is a qualitative test for detecting the presence of sugar in urine so there is no use in repeating it.

Medicine

Endocrinology

23b38f35-614f-44dc-8c09-58221d20da11

Pregnant women with obesity are at higher risk of following except?

Fetal macrosomia

Fetal distress

Gestational hypeension

Infections

multi

Ans. is 'd' i.e.,InfectionsIn a prospective multicenter study, pregnant females with obesity (BMI of 30-39.9) was associated with an increased risk of the following compared to non obese females:Gestational diabetes mellitusPreeclampsiaGestational hypeensionFetal macrosomia

Gynaecology & Obstetrics

f26ab4f3-018f-451d-8f63-d3711b865423

An elderly patient with hypeension with diabetes, proteinuria without renal failure, antihypeensive of choice is-

Furosemide

Methyldopa

Enalapril

Propranolol

single

Among the currently popular antihypeensive agents, angiotensin-conveing enzyme (ACE) inhibitors, such as captopril and enalapril, have been blamed, albeit rarely, for hepatotoxicity (primarily cholestasis and cholestatic hepatitis, but also hepatocellular injury) .Malignant hypeension (whenIV therapy is indicated) - Labetalol, nicardipine, nitroprusside,enalaprilat are preferred.in case of elderly patients with hypeension,diabetes as well as proteinuria without renal failure,enalapril can be used. ref:Harrison&;s principles of internal medicine,ed 18,pg no 628

Medicine

C.V.S

6b64b566-0b14-4001-aced-aba6dfdcda2c

Neonatal polycythemia with hyperviscosity is associated with all except

Twin - Twin transfusion syndrome

Fetal microsomia in gestational diabetes

Fetal and placental growth restriction

Transfusion at delivery

multi

Fetal macrosomia in gestational diabetes is associated with neonatal polycythemia.

Gynaecology & Obstetrics

3dcc2d48-f678-4bcf-adbf-102ccb0e4514

A 70-year-old man is evaluated in emergency department for symptoms of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. His past medical history is significant for hypertension, type 2 diabetes, chronic kidney disease, and hypothyroidism. Medications are furosemide, enalapril, atorvastatin, metformin, and insulin.On physical examination he has generalized cardiomegaly and pulmonary and systemic venous hypertension. The ECG is shown in Figure below. What is the cardiac rhythm seen on the ECG?

ectopic atrial tachycardia

atrial flutter with 2 :1 AV conduction

sinus tachycardia

supraventricular tachycardia

single

The cardiac rhythm is atrial flutter with 2:1 AV conduction. QRS complexes occur with perfect regularity at a rate of about 150/min. Their normal contour and duration indicate that ventricular activation occurs normally via the AV junction-His-Purkinje system. Flutter waves, regular ventricular rate at 150/min make the diagnosis of atrial flutter, rather than atrial fibrillation, sinus tachycardia, or ectopic atrial tachycardia.

Medicine

C.V.S.

8ffb4534-6bf9-4d4b-8fa9-703257502f19

Which of the following is used in management of diabetes?

Bromocriptine

Octreotide

Prednisolone

Pegvisomant

single

Answer- A. BromocriptineBromocriptine is recently included as antidiabetic.

Medicine

72940e71-f3dd-423f-b4fd-9ee331d91145

Which of the following is true about diazoxide except

K+ channel opener

>Can be used as antihypeensive agent

>Causes severe hypoglycemia

>Used in insulinoma

multi

Causes severe hypoglycemia Diazoxide Diazoxide is a direct acting aeriolar dilator. Diazoxide causes aeriolar dilatation with little effect on veins. Diazoxide prevents smooth muscle contraction and relaxes the aerioles Diazoxide is a potassium channel activator which causes local relaxation in smooth muscle by increasing membrane permeability to potassium ions. This switches off voltage gated calcium ion channel which inhibits the generation of action potential. When used as an intravenous antihypeensive agent diazoxide causes excessive hypotension. Diazoxide was formerlyused as an intravenous bolus dose for the at of hypeensive emergencies. But the dangers of excessive hypotension are now recognized to outweigh the benefit, and its emergency use is obsolete. Hypotension due to diazoxide has resulted in stroke and myocardial infarction. - The reflex sympathetic response due to hypotension can provoke angina, electrocardiographic evidence of ischemia and cardiac failure in patients with ischemic hea disease and diazoxide should be avoided in this situation. Diazoxide produces hyperglycemia by increasing insulin secretion, therefore it is used to treat various forms of hypoglycemia Diazoxide activates the same potassium channel in the pancreatic islet cells that is blocked by sulfonylureas. SullOnylureas close the potassium channels and increase insulin secretion whereas diazoxide opens the potassium channel in pancreatic islet cells and decrease insulin secretion. Due to its hyperglycemic action it is a useful drug for patients with chronic hypoglycemia from excess endogenous insulin secretion, either from an iselt cell tumour (insulinoma) or islet cell hyperplasia. According to Lawerence Diazoxide stimulates the ATP dependent r channel that is blocked by the sulphonylureas. Therefore its chronic use as an antihypeensive agent is precluded by the development of diabetes. Indeed its use in therapeutics should now be confined to rare indication of treating hypoglycemia due to islet cell tumour (insulinoma). Diazoxide is chemically related to thiazide diuretics. But in contrast to the structurally related thiazide diuretics, diazoxide causes renal salt and water retention.

Pharmacology

0acaa682-76e7-486a-afcb-7e2d993d2472

Which of the follow ing lesion is characteristic of diabetic nephropathy?

Hyaline arteriosclerosis

Nodular glomerulosclerosis

Renal Amyloid deposits

Fibrinoid necrosis

single

Ans: B (Nodular glomerulosclerosis) Ref: Robbins Pathologic Basis of Disease, 8th editionExplanation:Diabetic NephropathyThe term diabetic nephropathy is applied to the conglomerate of lesions that occur in the diabetic kidney.Most common lesions involve the glomeruli and are associated clinically with three glomerular syndromes;Non-nephrotic proteinuriaNephrotic syndromeChronic renal failureDiabetes also affects the arterioles (causing hyalinizing arteriolar sclerosis), increases susceptibility to the development of pyelonephritis and particularly papillary necrosis, and causes a variety of tubular lesions.The morphologic changes in the glomeruli includeCapillary basement membrane thickeningDiffuse mesangial sclerosisNodular glomerulosclerosis (Kimme- Istiel-Wilson lesions). Expansions non-coding regionsDiseaseProteinRepeatingSequenceSpinobulbar muscular atrophy (Kennedy Disease)Androgen ReceptorCAGHuntington DiseaseHuntingtonCAGDentatorubral-palidoluysian atrophy (Haw River Syndrome)Atrophin - 1CAGSpinocerebellar ataxia type 1Ataxin 1CAGSpinocerebellar ataxia type 2Ataxin-2CAGSpinocerebellar ataxia type 3 (Machado Joseph Disease)Ataxin 3CAGSpinocerebellar a taxia type 6Alpha 1a-Voltage-dependant calcium channel subunitCAGSpinocerebellar ataxia type 7Ataxin-7CAGThe morphology is identical in type 1 and type 2 diabetesThe Armanni-Ebstein change tor Armanni- Ebstein cells) consists of deposits of glycogen in the tubular epithelial cells (pars straight of proximal convoluted tubule and loop of Henle).

Pathology

Glomerular Diseases

fb42f13d-599b-4575-941d-f15c36830021

Radiation induced cataract is

Shield cataract

Antrior polar cataract

Posterior Subcapsular cataract

Alpo syndrome

single

Radiation can cause Posterior subcapsular cataract Lens is the most sensitive pa of eye for radiation induced damage Miscellaneous Cataract impoant for PGMEE * Sunflower cataract: Wilson disease, chalcosis. * Polychromatic Lusture- Complicated cataract * Coicosteroid: Posterior subcapsular cataract. (Topical steroids cause glaucoma, systemic steroids cause cataract more) * Galactosemia: Oil drop cataract * Anterior lenticonus- Alpo * Posterior Lenticonus- Lowe Syndrome * Rosette Cataract: Blunt trauma * Shield cataract- Atopic dermatitis. * Radiation can cause PSC cataract. * Persistent hyaloid aery: Cause of Posterior polar cataract * Myotonic Dystrophy: Christmas Tree Cataract (mimics the lights on a christmas tree) * Posterior polar cataract: Persistent hyperplastic primary vitreous * Snow storm/Snow flake cataract: Diabetes

Ophthalmology

Cataract

7c60a6a1-5abe-40f6-958e-5cc2332a949f

A 40yrs old man has chronic cough with fever for several months . The radiography reveals a diffuse reticulonodular Patten's.microscopically on transbronchial biopsy there are focal areas of inflammation conraining epithioid cell granuloma , Langerhans cells, lymphocytes, these findings are typically for which of the following type of hypersensitivity immunological response

Type1

Type2

Type3

Type4

multi

Ref Robbins 9/e p 210 T Cell-Mediated (Type IV) Hypersensitivity Several autoimmune disorders, as well as pathologic reactions to environmental chemicals and persistent microbes, are now known to be caused by T cells (Table 4-5). The occurrence and significance of T lymphocyte-mediated tissue injury have been increasingly appreciated as the methods for detecting and purifying T cells from patients' circulation and lesions have improved. This group of diseases is of great clinical interest because many of the new, rationally designed biologic therapies for immune-mediated inflam- matory diseases have been developed to target abnormal T cell reactions. Two types of T cell reactions are capable of causing tissue injury and disease: (1) cytokine-mediated inflammation, in which the cytokines are produced mainly by CD4+ T cells, and (2) direct cell cytotoxicity, mediated by CD8+ T cells (Fig. 4-12). In inflammation, exemplified by the delayed-type hypersensitivity (DTH) reaction, CD4+ T cells of the TH1 and TH17 subsets secrete cytokines, which recruit and activate other cells, especially macrophages, and these are the major effector cells of injury. In cell-mediated cytotoxicity, cytotoxic CD8+ T cells are responsible for tissue damage. Inflammatory Reactions Elicited by CD4+ T Cells The sequence of events in T cell-mediated inflammatory reactions begins with the first exposure to antigen and is essentially the same as the reactions of cell-mediated immunity (Fig. 4-4). Naive CD4+ T lymphocytes recognize peptide antigens of self or microbial proteins in association with class II MHC molecules on the surface of DCs (or macrophages) that have processed the antigens. If the DCs produce IL-12, the naive T cells differentiate into effector cells of the TH1 type. The cytokine IFN-g, made by NK cells and by the TH1 cells themselves, fuher promotes TH1 dif- ferentiation, providing a powerful positive feedback loop. If the APCs produce IL-1, IL-6, or IL-23 instead of IL-12, the CD4+ cells develop into TH17 effectors. On subsequent exposure to the antigen, the previously generated effector cells are recruited to the site of antigen exposure and are activated by the antigen presented by local APCs. The TH1 cells secrete IFN-g, which is the most potent macrophage- activating cytokine known. Activated macrophages have increased phagocytic and microbicidal activity. Activated macrophages also express more class II MHC molecules and costimulators, leading to augmented antigen presenta- tion capacity, and the cells secrete more IL-12, thus stimu- lating more TH1 responses. Upon activation by antigen, TH17 effector cells secrete IL-17 and several other cytokines, which promote the recruitment of neutrophils (and mono- cytes) and thus induce inflammation. Because the cyto- kines produced by the T cells enhance leukocyte recruitment and activation, these inflammatory reactions become chronic unless the offending agent is eliminated or the cycle is interrupted therapeutically. In fact, inflammation occurs as an early response to microbes and dead cells (Chapter 2), but it is greatly increased and prolonged when T cells are involved. Delayed-type hypersensitivity (DTH), described next, is an illustrative model of T cell-mediated inflammation and tissue injury. The same reactions are the underlying basis for several diseases. Contact dermatitis is an example of tissue injury resulting from T cell-mediated inflammation. It is evoked by contact with pentadecylcatechol (also known as urushiol, the active component of poison ivy and poison oak, which probably becomes antigenic by binding to a host protein). On reexposure of a previously exposed person to the plants, sensitized TH1 CD4+ cells accumulate in the dermis and migrate toward the antigen within the epidermis. Here they release cytokines that damage kera- tinocytes, causing separation of these cells and formation of an intraepidermal vesicle, and inflammation manifested as a vesicular dermatitis. It has long been thought that several systemic diseases, such as type 1 diabetes and mul- tiple sclerosis, are caused by TH1 and TH17 reactions against self antigens, and Crohn disease may be caused by uncon- trolled reactions involving the same T cells but directed against intestinal bacteria. T cell-mediated inflammation also plays a role in the rejection of transplants, described later in the chapter. Figure 4-12 Mechanisms of T cell-mediated (type IV) hypersensitivity reactions. A, In cytokine-mediated inflammatory reactions, CD4+ T cells respond to tissue antigens by secreting cytokines that stimulate inflammation and activate phagocytes, leading to tissue injury. B, In some diseases, CD8+ CTLs directly kill tissue cells. APC, antigen-presenting cell; CTLs, cytotoxic T lymphocytes. Cytokine-mediated inflammation Inflammation Tissue injury APC presenting tissue antigen Normal tissue CD4+ T cell Cell killing and tissue injury CD8+ CTLs Cytokines T cell-mediated cytolysis A B Delayed-Type Hypersensitivity DTH is a T cell-mediated reaction that develops in response to antigen challenge in a previously sensitized individual. In contrast with immediate hypersensitivity, the DTH reac- tion is delayed for 12 to 48 hours, which is the time it takes for effector T cells to be recruited to the site of antigen chal- lenge and to be activated to secrete cytokines. The classic example of DTH is the tuberculin reaction, elicited by chal- lenge with a protein extract of M. tuberculosis (tuberculin) in a person who has previously been exposed to the tuber- cle bacillus. Between 8 and 12 hours after intracutaneous injection of tuberculin, a local area of erythema and indura- tion appears, reaching a peak (typically 1 to 2 cm in diam- eter) in 24 to 72 hours and thereafter slowly subsiding. On histologic examination, the DTH reaction is characterized by perivascular accumulation ("cuffing") of CD4+ helper T cells and macrophages (Fig. 4-13). Local secretion of cyto- kines by these cells leads to increased microvascular per- meability, giving rise to dermal edema and fibrin deposition; the latter is the main cause of the tissue induration in these responses. DTH reactions are mediated primarily by TH1 cells; the contribution of TH17 cells is unclear. The tubercu- lin response is used to screen populations for people who have had previous exposure to tuberculosis and therefore have circulating memory T cells specific for mycobacterial proteins. Notably, immunosuppression or loss of CD4+ T cells (e.g., resulting from HIV infection) may lead to a nega- tive tuberculin response even in the presence of a severe infection. Prolonged DTH reactions against persistent microbes or other stimuli may result in a special morphologic pattern of reaction called granulomatous inflammation. The initial perivascular CD4+ T cell infiltrate is progressively replaced by macrophages over a period of 2 to 3 weeks. These accumulated macrophages typically exhibit morphologic evidence of activation; that is, they become large, flat, and eosinophilic, and are called epithelioid cells. The epitheli- oid cells occasionally fuse under the influence of cytokines (e.g., IFN-g) to form multinucleate giant cells. A micro- scopic aggregate of epithelioid cells, typically surrounded by a collar of lymphocytes, is called a granuloma (Fig. 4-14, A). The process is essentially a chronic form of TH1-mediated inflammation and macrophage activation (Fig. 4-14, B). Older granulomas develop an enclosing rim of fibroblasts and connective tissue. Recognition of a granuloma is of diagnostic impoance because of the limited number of conditions that can cause it (Chapter 2). T Cell-Mediated Cytotoxicity In this form of T cell-mediated tissue injury, CD8+ CTLs kill antigen-bearing target cells. As discussed earlier, class I MHC molecules bind to intracellular peptide antigens and present the peptides to CD8+ T lymphocytes, stimulat- ing the differentiation of these T cells into effector cells called CTLs. CTLs play a critical role in resistance to virus infections and some tumors. The principal mechanism of killing by CTLs is dependent on the perforin-granzyme system. Perforin and granzymes are stored in the granules of CTLs and are rapidly released when CTLs engage their targets (cells bearing the appropriate class I MHC-bound peptides). Perforin binds to the plasma membrane of th target cells and promotes the entry of granzymes, which are proteases that specifically cleave and thereby activate cellular caspases. These enzymes induce apoptotic death of the target cells (Chapter 1). CTLs play an impoant role in the rejection of solid-organ transplants and may contribute to many immunologic diseases, such as type 1 diabetes (in which insulin-producing b cells in pancreatic islets are destroyed by an autoimmune T cell reaction). CD8+ T cells may also secrete IFN-g and contribute to cytokine-mediated inflammation, but less so than CD4+ cells. Figure 4-14 Granulomatous inflammation. A, A section of a lymph node shows several granulomas, each made up of an aggregate of epi- thelioid cells and surrounded by lymphocytes. The granuloma in the center shows several multinucleate giant cells. B, The events that give rise to the formation of granulomas in type IV hypersensitivity reactions. Note the role played by T cell-derived cytokines. (A, Couesy of Dr. Trace Worrell, Depament of Pathology, University of Texas Southwestern Medical School, Dallas, Texas.) A Antigen-presenting cell CD4+ TH1 cell IL-12 TNF Monocytes Fibroblast IFN-g Giant cell Epithelioid cell B Lymphocyte Macrophage Antigen SUMMARY Mechanisms of T Cell-Mediated Hypersensitivity Reactions * Cytokine-mediated inflammation: CD4+ T cells are acti- vated by exposure to a protein antigen and differentiate into TH1 and TH17 effector cells. Subsequent exposure to the antigen results in the secretion of cytokines. IFN-g activates macrophages to produce substances that cause tissue damage and promote fibrosis, and IL-17 and other cytokines recruit leukocytes, thus promoting inflammation. * T cell-mediated cytotoxicity: CD8+ CTLs specific for an antigen recognize cells expressing the target antigen and kill these cells. CD8+ T cells also secrete IFN-g. With the basic mechanisms of pathologic immune reac- tions as background, we now proceed to a consideration of two categories of reactions that are of great clinical impor- tance: autoimmunity and transplant rejection. Figure 4-13 Delayed-type hypersensitivity reaction in the skin. A, Peri- vascular accumulation ("cuffing") of mononuclear inflammatory cells (lymphocytes and macrophages), with associated dermal edema and fibrin deposition. B, Immunoperoxidase staining reveals a predomiA nantly perivascular cellular infiltrate that marks positively with anti-CD4 antibodies. (B, Couesy of Dr. Louis Picker, Depament of Pathology, Oregon Health & Science University, Poland, Oregon.)

Anatomy

General anatomy

8319177a-4f1b-4fa7-bd35-2a278fa0c974

Painless loss of vision is seen in following except:

Vitreous hemorrhage

Optic atrophy

Developmental cataract

Acute Angle closure glaucoma.

multi

Ans. d Acute Angle closure glaucoma. (Ref Basak, Ophthalmology, 2nd ed., 215)# Vitreous hemorrhage is associated with sudden painless loss of vision & on attempted ophthalmoscopy the fundamental glow is characteristically absent as the fundus is hidden by a dark red haze of blood. It can occur due to retinal & vitreous detachment, in diabetes, sickle cell disease, hypertension & other ischemic diseases.# Common causes of sudden, painless vision loss include retinal detachment, retinal artery or vein occlusion, and ischemic optic neuritis. Cataracts and open angle glaucoma would be among the most common causes of painless vision loss that is gradual over the course of months or years.# Acute angle closure glaucoma is a cause of acute, painful vision loss.

Ophthalmology

Glaucoma

a4148ac9-580f-404e-9e1f-4dd30608a981

All of the following are causes of acalculous cholecystitis except:

Bile duct stricture

Schistosoma

Prolonged TPN

Major operations

multi

Causes of Acalculous Cholecystitis Elderly and critically ill patients after trauma Burns Longterm TPN Major operation (abdominal aneurysm repair and cardiopulmonary bypassQ) Diabetes mellitus

Surgery

Gallbladder

d0fd8328-8d07-447e-9e8b-d7ef0cc190e5

A 55-year-old obese woman complains of declining visual acuity. Funduscopic examination shows peripheral retinal microaneurysms. Urinalysis reveals 3+ proteinuria and 3+ glucosuria. Serum albumin is 3 g/dL, and serum cholesterol is 350 mg/dL. These clinicopathologic findings are best explained by which of the following mechanisms of disease?

Peripheral insulin resistance

Increased peripheral insulin uptake

Irregular insulin secretion

none of the above

multi

- Given clinical features point towards nephropathy & retinopathy resulted as complication of type-2 DM - Type-2 diabetes mellitus results from complex interplay b/w Underlying insulin resistance in its metabolic target tissues (liver, skeletal muscle & adipose tissue) & Reduction in glucose-stimulated insulin secretion, which fails to compensate for increased demand for insulin. - In obese persons, release of inhibitory mediators from adipose tissue interferes with intracellular signaling by insulin. - Hyperinsulinemia secondary to insulin resistance also downregulates number of insulin receptors on plasma membrane. Other choices are not related to pathogenesis of type 2 diabetes.

Pathology

Diabetes

78778ac3-5e24-4ab0-be90-3828d96a7941

Diabetes is associated with all of the following in the elderly EXCEPT

Cerebrovascular accident

Cognitive decline

Fall risk

Myocardial infarction

multi

Medicine

fe43aecd-b8ef-4660-bded-b6d31321c192

In a patient if administration of exogeneus vasopressin does not increase the osmolality of urine the likely cause is

SIADH

Psychogenic polydipsia

Renal Hyposensitivity to ADH

ADH Deficiency

single

Answer is C (Renal Hyposensitivity to ADH): Failure of urine osmolality to rise even after administration of exogenous ADH/vasopressin suggests a diagnosis of Nephrogenic Diabetes Insipidus due resistance to action of vasopressin on the Renal tubule (Renal Hyposensitivity to ADH).

Medicine

ddf0d9e7-c8d4-4500-89ce-b1ef7e0ff3e7

A person is being treated for Human Immunodeficiency Virus-1. He developed hyperiglyceridemia and hypercholesterolemia. Most likely drug implicated for these adverse effects is

Ritonavir

Raltegravir

Tenofovir

Eirenz

single

Ritonavir is a protease inhibitor and can cause hyperiglyceridemia and hypercholesterolemia. All protease inhibitors are metabolized by liver and all can cause metabolic abnormalities including hypercholesterolemia, diabetes mellitus, hyperlipidemia, insulin resistance and altered fat istribution (lipodystrophy). Atazanavir is devoid of this adverse effect. Tesamorelin is a synthetic analogue of growth hormone releasing factor indicated to reduce excess abdominal fat in HIV-infected patients with lipodystrophy.

Pharmacology

Anti-HIV Drugs

3a17848e-5035-41d7-b828-bd717f08c03d

Feature of diabetes mellitus in pregnancy:a) Postdatismb) Hydramniosc) Neonatal hyperglycemiad) ↑congenital defecte) PPH

bde

ade

ace

bce

single

As explained in the previous question maternal hyperglycaemia leads to fetal hyperglycaemia, which in turn causes polyuria and thus causes polyhydramnios. Polyhydramnios leads to preterm delivery and not post datism. Excessive uterine enlargement because of polyhydramnios and macrosomia causes increased incidence of atonic PPH. Diabetes leads to increased incidence of congenital defects in fetus. Maternal hyperglycemia → to fetal hyperglycemia → hyperinsulinemia → to neonatal hypoglycemia at birth.

Gynaecology & Obstetrics

907a1ee5-10f6-4abf-9a50-cc746adaa423

Which nerve is compressed in carpal tunnel syndrome -

Median nerve

Ulnar nerve

Radial nerve

Axillary nerve

single

Ans. is 'a' i.e., Median nerve f Ref: Basics of orthopaedics 2nd/e p. 718]Carpal tunnel syndromeo Carpal tunnel syndrome is the most common and widely known entrapment neuropathy in which the body's peripheral nerve is compressed or traumatized. Carpal tunnel syndrome occurs when the median nerve is compressed in the carpal tunnel below flexor retinaculum. The carpal tunnel is a narrow rigid passage way of ligament and bones at the base of hand, in front of distal part of wrist. Carpal tunnel houses the median nerve and 9 tendons (4 FDS, 4 FDP & FPL).Causes of carpal tunnel syndromeo There are many causes of carpal tunnel syndrome : -Idiopathic : - This is the most common cause.Pregnancy and menopauseMetabolic : - Gout, Diabetes mellitus4} Endocrine : - Hypothyroidism, Myxedema, Acromegaly, Hyperparathyroidism.Deposition disorder Amyloidosis, Sarcoidosis, Rheumatid arthritis, Leukemia, CRF, Nlucopoly saccharoidosis.AlcoholismLocal causes : - Malunited colie's fracture, osteo-arthritis of the carpal bones, synovitits of flexor tendon sheath, hematoma.Clinical features of carpal tunnel syndromeo Carpal tunnel syndrome is more common in women and occurs between 35-50years.o Symptoms usually start gradually, writh frequent burning, tingling,paresthesia and numbness in the distribution of median nerve, i.e., lateral three & half of fingers and lateral 2/3rd of palm,o The symptoms often first appear during night, since many people sleep with flexed wrists. (Flexion decreases the space in carpal tunnel which results in increased pressure over median nerve),o Sensory symptoms can often be reproduced by percussing over median nerve (Tinel's sign) or by holding the wrist fully flexed for a minute (Pltalen's test).o As the disease progresses, clumsiness of hand and impairment of digital function develop,o Later in the disease, there is sensory loss in median nerve distribution and obvious wasting of thenar eminence.Clinical Tests for Carpal tunnel syndromeo There are some provocative tests which act as important screening methods : -Wrist flexion (Phalen's test) : - The patient is asked to actively place the wrist in complete flexion. If tingling and numbness develop in the distribution of median nerve, the test is positive. This is the most sensitive provocative testTourniquet test : - A pneumatic BP cuff is applied proximal to the elbow' and inflated higher than the patient's systolic BP. The test is positive if there is paresthesia or numbness in the region of median nerve distribution in hand.Median nerve percussion test (Ttnel's sign) : - The median nerv e is gently tapped at the wrist. The test is positive if there is tingling sensation.;Median nerve compression test: - Direct pressure is exerted equally over both wrists by the examiner. If symptoms of carpal tunnel syndrome appear, the test is positive.

Orthopaedics

Peripheral Nerve Injuries

1cc21a8e-5355-4b28-a460-6737a6b8d783

Metabolic Syndrome has following features except

High triglycerides

High blood pressure

High blood sugar

High HDL levels

multi

The metabolic syndrome (syndrome X, insulin resistance syndrome) consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease (CVD) and diabetes mellitusThe major features of the metabolic syndrome include central obesity, hyperiglyceridemia, low levels of high-density lipoprotein (HDL) cholesterol, hyperglycemia, and hypeensionRef: Harrison; 19th ed; Pg 2449

Social & Preventive Medicine

Non communicable diseases

5e58e064-06c9-44f7-8a4b-f79b38a6adf0

Long term control of diabetes is assessed by

Random blood sugar

Microalbuminuria/ creatinine ratio

HbA2

HbA1c

single

Ans. D i.e. HbA1c

Medicine

609e514e-cfae-4b18-b4a2-b44e8807a427

A 45 year old male , known case of diabetes mellitus from last 15 years ,presents with Diabetic ketoacidosis . What shall be the initial line of management?

3 % saline

5% dextrose

0.9 % saline

Colloids

multi

Diabetic ketoacidosis (DKA) is a problem that affects people with diabetes . It occurs when the body stas breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Initial management is - 0.9% saline Treatment of choice - Insulin drip The use of 3% saline is not indicated because the patient has no neurologic deficits * Intracellular potassium shift out of cells in acidosis and cause a normal or even elevated potassium level but with improvement in the acidosis, it rapidly falls. (Insulin shifts potassium into intracellular compament thus resulting in fall of serum Potassium levels) Therefore, potassium repletion is critical.

Medicine

DNB 2018

2cd8f58f-8c19-4ac1-93eb-9400d0d970d2

Osteoporosis is seen in -

Thyrotoxicosis

Cushmg's disease

Menopause

All of the above

multi

Osteoporosis It refers to reduction ofbone mass per unit volume (loss of matrix and defective mineralisation) (Fig. 9.47). Aetiology 1.Involutional 2.Endocrinological 3.Gastrointestinal 4.Haematological 5.Rheumatological 6.Collagen vascular Normal bone Type I (postmenopausal) and Type II (senile) Hypehyroidism Hyperparathyroidism Diabetes mellitus Hypogonadism Cushing's syndrome Malnutrition Malabsorption Anorexia nervosa Multiple myeloma Mastocytosis Rheumatoid ahritis Marfan's syndrome Ehler-Danlos syndrome Osteogenesis imperfecta Osteoporosis Fig. 9.47 Anticonvulsants Steroids Vitamin A Alcohol Heparin Furosemide Thyroid hormone in excessive doses Lithium GnRH agonist Cyclosporin Cytotoxic drugs 8.Cigarette smoking 9.Glucocoicoid therapy 10.Hypogonadism 11.Alcoholism 12.Renal disease 13.GI/Hepatic disorders. Bone forming agents a.Fluoride--75 mg/day b.Anabolic steroids: Testosterone is used in the treatment of osteoporotic man with gonadal deficiency. R ALAGAPPAN MANUAL OF PRACTICAL MEDICINE FOUH EDITION PAGE NO-690

Medicine

Endocrinology

d6900265-17e6-48b5-92d1-a828d156d917

Predisposing factors of carcinoma endometrium are all EXCEPT

Obesity

Late menopause

Multiparity

Unopposed administration of estrogen

multi

(Multiparity) (573-74-Shaw's 14th)Multiparity is common in carcinoma cervix, while carcinoma of endometrium women are either nulliparous or of low parityPredisposing Factors in Carcinoma Endometrium* Peak incidence is 55-70 years* An Early menarche and late menopause is characteristic* Unopposed and unsupervised administration of HRT* Chronic non ovulatory cycles as seen in DUB* Familial predisposition - Familial Lynch II syndrome* Tamoxifen given to women with breast cancer increases the risk of endometrial hyperplasia* Combined oral hormonal pills* Obesity hypertension and diabetes* Infertile women and women with polycystic ovarian disease* Feminizing ovarian tumour at the time of diagnosis* The risk of endometrial carcinoma is the highest with the following complex hyperplasia with atypia** histological pattern of endometrial hyperplasia (about 28%)***

Gynaecology & Obstetrics

Miscellaneous (Gynae)

9f822821-43a4-4366-836e-648ac297e054

Following predispose to the high risk of vulvovaginal candidiasis except

HIV

Hypeension

Pregnancy

DM

multi

Several potential risk factors have been described, including the recent use of antibiotics and oral contraceptives, the presence of diabetes mellitus, dietary practices, gastrointestinal colonization by the organism, clothing and sanitary protection practices, sexual communicability of the organism, and HIV, DM, Ref ganong's review of medical physiology 25e 498

Physiology

All India exam

3854a4e9-6dad-4fea-b771-de00f38b08b3

30 year old female presents with a painful, red, warm nail fold since last 7 days. Patient is applying various home remidies like turmeric powder , warm saline compressions with out any relief .The most probable diagnosis is

Ingrowing finger nail

Acute paronychia

Chronic paronychia

Onychomycosis

single

Paronychia is inflammation around a finger or toenail. Paronychia is a nail disease that is an often tender bacterial or fungal infection of the hand or foot, where the nail and skin meet at the side or the base of a finger or toenail. The infection can sta suddenly (acute paronychia) or gradually (chronic paronychia) signs and symptoms: The skin typically presents as red, itchy, and hot, along with intense pain. Pus is usually present, along with gradual thickening and browning discoloration of the nail plate. Causes: *Acute paronychia is usually caused by bacteria. Paronychia is often treated with antibiotics, either topical or oral or both. Chronic paronychia is most often caused by a yeast infection of the soft tissues around the nail but can also be traced to a bacterial infection. If the infection is continuous, the cause is often fungal and needs antifungal cream or paint to be treated. Risk factors include repeatedly washing hands and trauma to the cuticle such as may occur from repeated nail biting. In the context of baending, it is known as bar rot. Prosector's paronychia is a primary inoculation of tuberculosis of the skin and nails, named after its association with prosectors, who prepare specimens for dissection. Paronychia around the entire nail is sometimes referred to as runaround paronychia. Painful paronychia in association with a scaly, erythematous, keratotic rash (papules and plaques) of the ears, nose, fingers, and toes may be indicative of acrokeratosis paraneoplastica, which is associated with squamous cell carcinoma of the larynx. Paronychia can occur with diabetes, drug-induced immunosuppression,or systemic diseases such as pemphigus. Treatment: When no pus is present, warm soaks for acute paronychia are reasonable, even though there is a lack of evidence to suppo its use.Antibiotics such as clindamycin or cephalexin are also often used, the first being more effective in areas where MRSA is common.If there are signs of an abscess (the presence of pus) drainage is recommended. Chronic paronychia is treated by avoiding whatever is causing it, a topical antifungal, and a topical steroid. In those who do not improve following these measures, oral antifungals and steroids may be used or the nail fold may be removed surgically Ref Harrison 20th edition pg 1234

Dental

miscellaneous

7437be19-31e0-4922-a64d-05046be19976

A 66-year-old man presents with a sudden onset of diabetes, anorexia, weight loss, epigastric pain with radiation to back. Next best investigation for this patient is?

Ultrasound of abdomen

CT abdomen

Enteroclysis

Triple contrast barium enema

single

Ans. B CT abdomenRef: Bailey and Love: 26th ed. page 1137* The clinical history of epigastric pain radiating to back points to pancreatic etiology. This patient may have developed pancreatic cancer. Sudden onset of diabetes in the elderly is also suggestive. The best imaging modality to image chronic pancreatitis or pancreatic malignancy is CT abdomen.* Choice A is ruled out as gas shadows of stomach obscure ultrasound view of pancreas.* Choice C is fluoroscopic intubation-infusion small- bowel examination which is used to evaluate for small bowel pathology while this patient has pancreatic lesion* Choice D is ruled out as it used for large bowel evaluation.

Physiology

Misc.

91ec5518-373b-4a7e-9246-d7a72ba7640c

Site of transplantation in Islet cell transplant for Diabetes mellitus is

Skin

Injected into the poal vein

Liver

Pelvis

single

The islets are then purified from the dispersed tissue by density-gradient centrifugation and can be delivered into the recepient liver (the preferred site for transplantation) by injection into the poal vein Ref: Bailey and love 27th edition Pgno :1552

Anatomy

General anatomy

3d79ea96-adfd-4e79-8aaa-12ca93909a6f

Mody false is -

Age <25 years

Impaired secretion of insulin

Responds to sulfonylureas

Insulin dependent

multi

Ans. is 'd' i.e., Insulin dependent Maturity onset diabetes of the young (MODY) o This is characterized by non-insulin dependent diabetes mellitusQ o The usual age of onset is 25 years or youngerQ o Patients are nonobese and their hyperglycemia is due to impaired glucose induced secretion of insulinQ. o It generally responds well to low doses of oral hypoglycemic agentsQ. Tvpe II diabetes mellitus - o In this type of diabetes obesity, insulin resistance and relative insulin deficiency are key findings. Insulin secretion is usually sufficient to prevent ketosis under basal conditions, o It is common in obese individuals but can occur in non obese too. o The diabetes is usually controlled with oral hypoglycemic agentsQ (insulin is usually not required). So. How to differentiate between MODYand diabetes mellitus type II ???. Diagnostic criteria for the diagnosis of MODY include : o Not insulin-dependent - sho wn by absence of insulin treatment 5 years after diagnosis or significant C-peptide in a patient on insulin treatment. o Rarely obese (obesity is not required for the development of diabetes). o Early diagnosis of diabetes - before age 25 years in at least one and ideally two family members. o Autosomal dominant inheritance i.e. vertical transmission of diabetes through at least two generations (ideally three generation), with a similar phenotype in cousins or second cousins. o Diabetes results from b-cell dysfunction (insulin levels are often in the normal range, though inappropriately low for the degree of hyperglycemia). Type I Type II Mody Age of onset Predominantly young Predominantly middle to old age Predominantly yound (usually < 25 years) Family history Not significant (ucommon) Significant (Positive) Inheritance is Polygenic/Heteroaenous Vertical transmission through successive generations is not essential for diagnosis Signi ficant (Positive) Inheritance is Monoeenic/Autosomal dominant Vertical transmission through at least two successivegeneration (ideally three) is essential for diagnosis Risk of ketoacidosis High Low (uncommon) Low (uncommon ) Insulin dependence Insulin dependent Non insulin dependent Non insulin dependent Obesity Uncommon (may be present) Common (may be absent) Uncommon (may be present) Pathophysiology b cells dysfunction (Autoantibodies against b cells) No insulin resistance bcell dysfunction Insulin resistance b cell dysfunction No insulin resistance Fasting 'C' pcptide/insulin Low High Low

Medicine

Diabites & Inappropriate Antidiuretic Hormone

aa3af173-4296-4a04-84f4-6b67814329be

Oral glucose tolerance test in children is done with

1.5 gm/kg glucose

1.75 gm/kg glucose

2 gm/kg glucose

2.5 gm/kg glucose

single

Ideal weight of the glucose taken for glucose tolerance test for children are 1.75gm/kg glucose . Obtain a fasting blood sugar level, then administer an oral glucose load (2 g/kg for children aged < 3 y, 1.75 g/kg for children aged 3-10 y , or 75 g for children aged >10 y). Check the blood glucose concentration again after 2 hours. A fasting whole-blood glucose level higher than 120 mg/dL (6.7 mmol/L) or a 2-hour value higher than 200 mg/dL (11 mmol/L) indicates diabetes. However, mild elevations may not indicate diabetes when the patient has no symptoms and no diabetes-related antibodies. Reference: GHAI Essential pediatrics, 8th edition

Pediatrics

Endocrinology

cc63fd13-ab98-42ce-85fe-ee00e4891f85

All of the following are features of Friadreich's Ataxia, Except:

Prograssive Ataxia is the most common presentation

Cardiomyopathy is a common association

Diabetes mellitus may be associated

Extensor plantar with brisk lower limb reflexes.

multi

Answer is D (Extensor plantar with brisk lower limb reflexes): Friedreich's Ataxia, is characteristically associated with an extensor plantar response but absent lower limb reflexes. Lower limb reflexes are characteristically absent (in most patients) and not brisk. Cardiomyopathy is a common association seen in up to 90% of patients Diabetes mellitus may be associated in up to 25% of cases Progressive ataxia is the most common presenting symptom.

Medicine

193bb7c1-ba4e-4928-bcbf-9be0f7878eba

An 83-year-old man with Parkinson's disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?

oropharyngeal flora

tuberculosis

Staphylococcus aureus

Pseudomonas aeruginosa

single

Most lung abscesses and all anaerobic abscesses involve the normal flora of the oropharynx. Septic embolic usually contain S. aureus. Factors that predispose to Gram-negative colonization of the oropharynx include hospitalization, debility, severe underlying diseases, alcoholism, diabetes, and advanced age. Impaired consciousness, neurologic disease, swallowing disorders, and nasogastric or endotracheal tubes all increase the likelihood of aspiration.

Medicine

Respiratory

faa271b0-0ba6-4ad4-a8b7-0647087451b8

Pituitary diabetes insipidus is improved by?

Water restriction

Lithium

Chlorpropamide

Chlohiazide

single

CHLORPROPAMIDE : This Anti-diabetic drug was withdrawn from market as it causes SIADH. So theoretically, it can be used in diabetes insipidus. But the DOC for treatment of Central Diabetes Insipidus: Desmopressin

Medicine

Disorders of pituitary gland

5dd21e15-236d-401e-8d9d-00e0ec553c01

Chronic calcific pancreatitis is associated with all of the following except: September 2005

Hypercalcemia

Diabetes mellitus

Malabsorption of fat

Diabetes associated complications are uncommon

multi

Ars. A: Hypercalcemia Chronic calcifying pancreatitis is invariably related to alcoholism. The earliest finding is precipitation of proteinaceous material in the pancreatic ducts that forms protein plugs that subsequently calcify. The pancreatic ductal epithelium undergoes atrophy, hyperplasia, and metaplasia at the site of the protein plugs. Chronic pancreatitis is a relapsing condition that presents with abdominal pain. As the disease progresses, the frequency and duration of episodes of abdominal pain increase. Consequently, narcotic addiction is a common problem because of the intractable pain. Weight loss and malabsorption are also common. Diabetes can develop in more than half of patients with chronic calcific pancreatitis. Diabetes tends to be brittle in these patients, probably because of the lack of both insulin and glucagon. However, patients with diabetes associated with chronic pancreatitis are less prone to complications such as retinopathy, nephropathy, atherosclerosis, and ketoacidosis than are patients with primary diabetes. On the other hand, neuropathy and myopathy can occur in one third of patients with chronic pancreatitis-associated diabetes

Surgery

b5efd00f-878a-47d4-b56c-be839eb1025c

All are seen in cirrhosis of liver except

Enlargement of testis

Gynaecomastia

Absence of pubic and facial hair

Loss of libido

multi

(A) (Enlargement of testes) (943- Davidson 22nd)Clnical features of hepatic cirrhosis* Hepatomegaly (although liver may also be small)* Jaundice* Ascites* Circulatory changes spider telangiectasia, palmar erythema, cyanosis* Endocrine changes; loss of libido, hair lossMen; gynaecomastia, testicular atrophy, impotenceWomen ; breast atrophy, irregular menses, amenorrhoea* Haemorrhagic tendency; bruises, purpura, epistaxis* Portal hypertension; splenomegaly, collateral vessels, variceal bleeding* Hepatic (portosystemic) encephalopathy* Other features; pigmentation, digital clubbing, Dupuytren's contractureCommon precipitants of Hepaic Encephalopathy includeA. Increased nitrogen load as in;B. Electrolyte and Metabolic imbalance such as in1. GI bleeding1. Hypokalemia2. Excessive dietary protein intake2. Alkalosis3. Azotemia3. Hypoxia4. Constipation4. HyponatremiaC. Drugs: CNS depressant agents like narcotics, tranquillizers, sedativesD. Miscellaneous conditions like; infection0, surgeryQ, superimposed acute liver disease0* Anaemia may lead to cellular hypoxia at the level of liver cells and thus ppt, encephalopathyQ* Barbiturates are CNS depressant drugs and their injudicious use, therefore may precipitate hepaticQ encephalopathy,* Hypothyroidism, though not mentioned as a diret precipitating, factor, may contribute towards precipitating encephalopathy by causing constipation' or slowing down the intellectual and motor activity* Cause of vasodilatation in spider nevi is - Estrogen* Most common cause of pyogenic liver abscese is Biliary Tract Infections**HIGH YIELD FACTS1. Octreotide / Somatostatin analogue are agents of choice for medical management of variceal bleed. **2. Desmopressin is the drug of choice for central Diabetes Insipidus (Pituitary DI or Neurohypophyseal DI)

Medicine

G.I.T.

f133751d-3c4b-4581-996e-cc2240ededfa

A 37 yr old male brought to emergency room late after road traffic accident . On examination the capillary refilling time is delayed in the left lower limb . All are indications for amputation in this patient, except?

Transcutaneous Oxygen Tension - 40mmHg

Severe Peripheral Vascular disease

Ankle-Brachial Index < 0.45

Fulminant Gas Gangrene

multi

Causes of Amputations 'three Ds': (1) Dead, (2) Dangerous (3) Damned nuisance. Dead (or dying) Peripheral vascular disease accounts for almost 90% of all amputations. Other causes of limb death are Severe trauma, burns and frostbite. Dangerous disorders are malignant tumours, potentially lethal sepsis (Gas Gangrene) and crush injury. Damned nuisance: In some cases retaining the limb may be worse than having no limb at all. This may be because of: (1) pain; (2) gross malformation; (3) recurrent sepsis or (4) severe loss of function. Transcutaneous Oxygen Tension (TcPO2)values > 40 mmHg are indicative of healing whereas values < 20 mmHg are indicative of non-healing and impending limb loss. For values between20- 40 mmHg, the clinician needs to consider co-morbidities like vascular disease, diabetes etc and the patient's nutritional status before considering amputation. Ankle-brachial Index (ABI) > 0.9 indicates absence of vascular injury and values < 0.45 indicate severe injury.

Orthopaedics

Amputations and Spos Injury

506bb446-441a-4f49-a44b-187a10cc1542

Regarding synthesis of triacylglycerol in adipose tissue, all of the following are true except

Synthesis from Dihydroxyacetone phosphate

Enzyme Glycerol Kinase plays an impoant role

Enzyme Glycerol 3 phosphate dehydrogenase plays an impoant role

Phosphatidate is hydrolyzed

multi

SYNTHESIS OF TRIGLYCERIDES (TAG) Liver and adipose tissue are the major sites of triacylglycerol (TAG) synthesis. The TAG synthesis in adipose tissue is for storage of energy whereas in liver it is mainly secreted as VLDL and is transpoed to peripheral tissues. The TAG is synthesised by esterification of fatty acyl CoA with either glycerol-3-phosphate or dihydroxyacetone phosphate (DHAP).The glycerol pa of the fat is derived from the metabolism of glucose. DHAP is an intermediate of glycolysis. Glycerol-3-phosphate may be formed by phosphorylation of glycerol or by reduction of dihydroxyacetone phosphate (DHAP). In adipose tissue, glycerol kinase is deficient and the major source is DHAP derived from glycolysis. However, in liver glycerol kinase is active. The fatty acyl CoA molecules transfer the fatty acid to the hydroxyl groups of glycerol by specific acyltransferases. In addition to these two pathways, in the intestinal mucosal cells the TAG synthesis occurs by the MAG pathway. The 2-MAG absorbed is re-esterified with fatty acyl CoA to form TAG (Fig. 11.4). Esterification of fatty acyl CoA with glycerol phosphate to form triacylglycerol occurs at a rapid rate during the fed state. Under conditions of fasting, it is seen that synthesis of triacylglycerol occurs side by side with lipolysis since the free fatty acid level is high in plasma. The glycerol phosphate is derived from the metabolism of glucose in the fed state by channeling dihydroxyacetone phosphate, an intermediate of glycolysis. In the fasting state, the glycerol phosphate is derived from dihydroxyacetone phosphate formed during gluconeogenesis (neoglycerogenesis). The activity of the enzyme PEPCK is enhanced in liver and adipose tissue during conditions of fasting so that glycerol phosphate is available to esterify and store the excess fatty acid mobilized.METABOLISM OF ADIPOSE TISSUE The adipose tissue serves as a storage site for excess calories ingested. The triglycerides stored in the adipose tissue are not ine. They undergo a daily turnover with new triacylglycerol molecules being synthesized and a definite fraction being broken down. 1. Adipose Tissue in Well-fed Condition i. Under well-fed conditions, active lipogenesis occurs in the adipose tissue. ii. The dietary triglycerides transpoed by chylomicrons and the endogenously synthesised triglycerides from liver brought by VLDL are both taken up by adipose tissue and esterified and stored as TAG. The lipoprotein molecules are broken down by the lipoprotein lipase present on the capillary wall. iii. In well-fed condition, glucose and insulin levels are increased. GluT4 in adipose tissue is insulin dependent. Insulin increases the activity of key glycolytic enzymes as well as pyruvate dehydrogenase, acetyl CoA carboxylase, and glycerol phosphate acyltransferase. The stimulant effect of insulin on the uptake of glucose by adipose tissue, on the glycolysis and on the utilisation of glucose by the HMP pathway also enhances lipogenesis. iv. Insulin also causes inhibition of hormone-sensitive lipase, and so lipolysis is decreased2. Adipose Tissue in Fasting Condition i. The metabolic pattern totally changes under conditions of fasting. TAG from the adipose tissue is mobilized under the effect of the hormones, glucagon and epinephrine. ii. The cyclic AMP-mediated activation cascade enhances the intracellular hormone sensitive lipase.The phosphorylated form of the enzyme is active which acts on TAG and liberates fatty acids. iii. Under conditions of starvation, a high glucagon, ACTH, glucocoicoids, and thyroxine have lipolytic effect. The released free fatty acids (FFA) are taken up by peripheral tissues as a fuel.3. Adipose Tissue and Diabetes Mellitus Lipolysis is enhanced and high FFA level in plasma is noticed in diabetes mellitus. The insulin acts through receptors on the cell surface of adipocytes. These receptors are decreased, leading to insulin insensitivity in diabetes. In type 2 diabetes mellitus, there is insulin resistance and the different insulin signaling pathways are affected differently. Hepatic gluconeogenesis occurs uninhibited leading to hyperglycemia. However, increased mobilization of fatty acids from adipose tissue and the persistently high free fatty acid levels in the presence of hyperinsulinemia stimulate synthesis of triacylglycerol. The overproduction of TAG leads to increased release of VLDL from liver causing hyperiglyceridemia. The excess deposition of TAG in adipose tissue accounts for the obesity prevalent in type 2 diabetes patients. 4. Adipose Tissue and Obesity The fat content of the adipose tissue can increase to unlimited amounts, depending on the amount of excess calories taken in. This leads to obesity. Plasma insulin level is high. But the insulin receptors are decreased, and there is peripheral resistance against insulin action. When fat droplets are overloaded, the nucleus of adipose tissue cell is degraded, cell is destroyed, and TAG becomes extracellular. Such TAG cannot be metabolically reutilized and forms the dead bulk in obese individuals.Ref: DM Vasudevan - Textbook of Biochemistry, 8th edition, page no: 139-141

Biochemistry

Metabolism of lipid

b7d9688e-4eb7-4d3a-ae88-01e1ac397d54

Duputryens contracture commonly affects: September 2005

Little finger

Ring finger

Middle finger

Index finger

single

Ans. B: Ring Finger Dupuytren's contracture is more common among people with diabetes, alcoholism, or epilepsy. Dupuytren contracture, a disease of the palmar fascia, results in the thickening and shoening of fibrous bands in the hands and fingers. The ring finger is the one affected most commonly. It is usually limited to the medial three fingers. This disease entity belongs to the group of fibromatoses that include plantar fibromatosis (Ledderhose disease), penile fibromatosis (Peyronie disease), and fibromatosis of the dorsal proximal interphalangeal (PIP) joints (Garrod nodes or knuckle pads).

Surgery

561f6314-6a70-44a7-9b05-4b60f7201797

Increased acetylcholinesterase in amniotic fluid indicates -

Open neural tube defects

Oesophageal atresia

Down syndrome

Edwards syndrome

single

(A) (Open neural tube defects) (1998 - Nelson 19th)* Failure of closure of the neural tube allows excretion of fetal substances (a-fetoprotein , acetylecholinesterase) into the amniotic fluid, serving as biochemical and markers of a neural tube defects (NTD).* Prenatal screening of maternal serum of AFP in the 16th - 18th week gestation is an effective method for identifying pregnancies at risk for features with NTDA in utero.* Risk factor for neural tube defects (william obs)i) Family history of NTD-First degree relative 2 - 3% Autosomal dominant or Autosomal recessive - 20 - 3% times highter.ii) Exposure to certain environmental agents, malnutrition.iii) Diabetes (Hyper glycemia/Matemal obesity).iv) Hyperthermiav) Drugs - valproic acid, carbamazepine, Aminopterin and isotretinoin (Anacephaly or encephalocele)vi) Genetic syndrome with known recurrence risk Meckel - Gruber, Roberts - SC, Phocomelia, Jarco Levin and HARDE syndrome.vii) Trisomy 13 and 18 and Triploidy all have 1% recurrence risk.* Major NTDs include - spina bifida occulta, meningocele, myelomeningocele, encephalocele, anencephaly, caudal regression syndrome, dermal sinus, tethered cord, syringomyelia, diastematomyelia and lipoma involving the conus medullaris and / or filum terminale and the rare condition anencephaly.Prevention - The U.S. Public health service has recommended that all women of child bearing age and who are capable of becoming pregnant take 0.4 mg folic acid daily.* Nuchal translucency is used for screening of Down syndrome in antenatal USG**

Pediatrics

Miscellaneous

4b5c6a1c-cb79-4c70-be72-40389732c847

True about NPCDCS is all except

Separate centre for stroke, DM

Implementation in some 5 states over 10 district

CHC has facilities for diagnosis and treatment of CVD, Diabetes

Day care facilities are available at subcentre

multi

Ans. c. CHC has facilities for diagnosis and treatment of CVD, Diabetes The NPCDCS program has two components viz. (i) Cancer and (ii) Diabetes, CVDs and Stroke. These two components have been integrated at different levels as far as possible for optimal utilization of the resources. The activities at State, Districts, CHC and Sub Centre level have been planned under the programme and will be closely monitored through NCD cell at different levels. The strategies proposed will be implemented in 20,000 Sub Centres and 700 Community Health Centre in 100 Districts across 21 States during 2010-12. O " height="592" align="left" width="63">Early diagnosis of diabetes, CVDs, Stroke and Cancer is done at District Hospital, not at CHC. Packages of services to be made available at different levels under NPCDCS Health Facility Packages of services Sub centre Health promotion for behavior change 'Oppounistic' Screening using B.P. measurement and blood glucose by strip method Referral of suspected cases to CHC CHC Prevention and health promotion including counselingdeg Early diagnosisdeg through clinical and laboratory investigations Common lab investigations: Blood Sugar, lipid profile, ECG, Ultrasound, X- ray etc.) Management of common CVD, diabetes and stroke cases (outpatient and in patients.)deg Home based care for bed ridden chronic cases Referral of difficult cases to District Hospital/higher health care facility District Hospital Early diagnosis of diabetes, CVDs, Stroke and CancerdegInvestigations: Blood Sugar, lipid profile, Kidney Function Test (KFT), Liver Function Test (LFT), ECG, Ultrasound, X-ray, colposcopy , mammography etc. (if not available, will be outsourced) Medical management of cases (Outpatient, inpatient and intensive Care )4. Follow up and care of bed ridden cases 5. Day care facility6. Referral of difficult cases to higher health care facility7. Health promotion for behavior change Teiary CancerCentre Comprehensive cancer care including prevention, early detection, diagnosis, treatment, minimalaccess surgery after care, palliative care and rehabilitation

Social & Preventive Medicine

51b0ec24-5a87-41a7-b7c9-9209b59c815b

Stroke is common in -

Mania

Depression

Bipolar disorder

Schizophrenia

single

The rates of co-morbidity are higher in patients with some psychiatric disorders, compared to general population. Stroke, Ischemic heart disease, and diabetes are more common in Schizophrenia and bipolar disorder (schizophrenia >bipolor disorder). Hypertension is more common in bipolar disorder and schizophrenia (bipolor disorder > Schizophrenia). Epilepsy is more common in schizophrenia and bipolor disorder (Schizophrenia = Bipolor disorder).

Psychiatry

c4bd1268-abae-4f12-bb8e-82a2cf060c4d

Physiological jaundice of newborn may be managed by all except -

Metalloporphyrin

Phenytoin sodium

Phototherapy

None of the above

multi

Ans. b (Phenytoin sodium). (Ref. Nelson Textbook of Pediatrics 17th ed., 593, 597) # Jaundice during the 1st 24 hrs of life warrants diagnostic evaluation and should be considered to be due to hemolysis until proved otherwise. Septicemia and intrauterine infections such as syphilis, cytomegalovirus, and toxoplasmosis should also be considered, especially in infants with an increase in plasma direct-reacting bilirubin. # Jaundice after the 1st 24 hrs may be "physiologic" or may be due to septicemia, hemolytic anemia, galactosemia, hepatitis, congenital atresia of the bile ducts, inspissated bile syndrome after erythroblastosis fetalis, syphilis, herpes simplex, or other congenital infections. Physiologic jaundice (icterus neonatorum) # Under normal circumstances, the level of indirect-reacting bilirubin in umbilical cord serum is l-3mg/dL and rises at a rate of less than 5mg/dL/24hr; thus, jaundice becomes visible on the 2nd-3rd day, usually peaking between the 2nd and 4th days at 5-6 mg/dL and decreasing to below 2mg/dL between the 5th - 7th days of life. # Jaundice associated with these changes is designated "physiologic" and is believed to be the result of increased bilirubin production after the breakdown of fetal red blood cells combined with transient limitation in the conjugation of bilirubin by the liver. # Risk factors for indirect hyperbilirubinemia include maternal diabetes, race (Chinese, Japanese, Korean, and Native American), prematurity, drugs (vitamin K3, novobiocin), altitude, polycythemia, male sex, trisomy 21, cutaneous bruising, cephalohematoma, oxytocin induction, breastfeeding, weight loss (dehydration or caloric deprivation), delayed bowel movement, and a sibling who had physiologic jaundice. # A family history of neonatal jaundice, exclusive breastfeeding, bruising, cephalohematoma, Asian race, and maternal age older than 25 yr identify approximately 60% of cases of extreme hyperbilirubinemia. # Indirect bilirubin levels in full-term infants decline to adult levels (mg/dL) by 10-14 days of life. # Persistent indirect hyperbilirubinemia beyond 2 wk suggests hemolysis, hereditary glucuronosyl transferase deficiency, breast milk jaundice, hypothyroidism, or intestinal obstruction. Jaundice associated with pyloric stenosis may be due to caloric deprivation, deficiency of hepatic UDP-glucuronyl transferase or ileus-induced increased enterohepatic circulation of bilirubin. Treatment of hyperbilirubinemia Phototherapy # Clinical jaundice and indirect hyperbilirubinemia are reduced on exposure to a high intensity of light in the visible spectrum. # Bilirubin absorbs light maximally in the blue range (420-470 nm). Nonetheless, broad-spectrum white, blue, special narrow-spectrum (super) blue, less often, green lights are effective in reducing bilirubin levels. # Bilirubin in the skin absorbs light energy, which by photo-isomerization converts the toxic native unconjugated 4Z, 15Z-bilirubin into the unconjugated configurational isomer 4Z,15E-bilirubin. # Phototherapy also converts native bilirubin, by an irreversible reaction, to the structural isomer lumirubin, which is excreted by the kidneys in the unconjugated state. # When indications for exchange transfusion are present, phototherapy should not be used as a substitute. # However, phototherapy may reduce the need for repeated exchange transfusions in infants with hemolysis. # Phototherapy is indicated only after the presence of pathologic hyperbilirubinemia has been established. # The basic cause or causes of jaundice should be treated concomitantly. # Prophylactic phototherapy in VLBW infants may prevent hyperbilirubinemia and may reduce the incidence of exchange transfusions. # Dark skin does not reduce the efficacy of phototherapy. # Maximal intensive phototherapy should be used when indirect bilirubin levels approach. Such therapy includes "special blue" fluorescent tubes, placing the lamps within 15-20 cm of the infant, and placing a fiberoptic phototherapy blanket under the infant's back to increase the exposed surface area. # Complications of phototherapy include loose stools, erythematous macular rash, a purpuric rash associated with transient porphyrinemia, overheating and dehydration (increased insensible water loss, diarrhea), chilling from exposure of the infant, and bronze baby syndrome. # Phototherapy is contraindicated in the presence of porphyria. # The term bronze baby syndrome refers to a dark grayish brown discoloration of the skin sometimes noted in infants undergoing phototherapy. Almost all infants observed with this syndrome have had a mixed type of hyperbilirubinemia with significant elevation of direct-reacting bilirubin and often with other evidence of obstructive liver disease. # Those using phototherapy should remain alert to these possibilities and avoid any unnecessary use because untoward effects on DNA have been demonstrated in vitro. Exchange transfusion. # Exchange transfusion is performed if intensive phototherapy has failed to reduce bilirubin levels to a safe range and if the risk of kernicterus exceeds the risk of the procedure or the infant has signs of kernicterus. # Potential complications from exchange transfusion are not trivial and include acidosis, electrolyte abnormalities, hypoglycemia, thrombocytopenia, volume overload, arrhythmias, NEC, infection, graft vs host disease, and death. # The appearance of clinical signs suggesting kernicterus is an indication for exchange transfusion at any level of serum bilirubin. Other therapies # Tin (Sn)-protoporphyrin (or tin-mesoporphyrin) administration has been proposed for reduction of bilirubin. It may inhibit the conversion of biliverdin to bilirubin by heme oxygenase. A single intramuscular dose on the 1st day of life may reduce the need for phototherapy. Such therapy may be beneficial when jaundice is anticipated (G6PD deficiency) or when blood products are discouraged (Jehovah's Witness). Complications include transient erythema if the infant is receiving phototherapy. # IV immunoglobulin (500 mg/kg/dose over a 4hr period), given ql2hr for 3 doses, is effective in reducing bilirubin levels in patients with Coombs-positive hemolytic anemia, presumably by reducing hemolysis.

Unknown

f09ed125-f426-4aa4-9cd1-0ca304cf0787

Drug which is useful in neuronal diabetes inspidus in both children and adults given intra nasally -

Vasopressin

Desmopressin

Lypressin

Presselin

multi

Ans. is 'b' i.e., Desmopressin Desmopressin (intranasal) is the DOC for central DI.

Pharmacology

aa6c5cbe-a0d3-41dd-a133-86704b55af0e

Caudal regression syndrome is seen in

Preeclampsia

Gestational diabetes

Sickle-Cell anemia

Systemic lupus erythematosus

single

Gestational diabetes is associated with caudal regression syndrome.

Gynaecology & Obstetrics

e4958250-5d35-4cae-8d1e-af35dec6617d

Aldose reductase inhibitor drugs are useful in

Cataract

Diabetes mellitus

Hereditary fructose intolerance

Essential fructosuria

single

Ans. is 'b' i.e., Diabetes mellitus Aldose reductase catalyzes the NADPH-dependent conversion of glucose to sorbitol, the first step in polyol pathway of glucose metabolism. Aldose reductase inhibitors are a class of drugs being studied as a way to prevent eye and nerve damage in people with diabetes mellitus. Examples of aldose reductase inhibitors include: Tolrestat (withdrawn from market) Apalrestat Ranirestat Fidarestat

Medicine

6a8cedf9-21c8-4a97-a4a3-2426d5352004

Which of the following characteristics is not of much impoance in a screening test

Low cost

High safety margin

High sensitivity

High specificity

single

High specificity All are impoant attributes of screening test but among them high specificity is less impoant as Park states -'Screening test is not intended to be a diagnostic test. It is only an initial examination. Those who are found to have positive test results are refen-ed to a physician for fuher diagnostic work-up & treatment. High specificity is a necessary attribute for a diagnostic test. Below are given the differences between screening and diagnostic tests. Screening test Diagnostic test * Done on apparently healthy Done on those with indications or sick (asymptomatic) * Applied to groups Applied to single patients, all diseases are considered * Test results are arbitrary and final Diagnosis is not final but modified in light of new evidence, diagnosis is the sum of all evidence 4. Based on one criterion or cut-off Based on evaluation of a number of symptoms, signs and point (e.g., diabetes) laboratory findings Less accurate More accurate 6. Less expensive More expensive 7. Not a basis for treatment Used as a basis for treatment 8 The initiative comes from the investigator or agency providing care The initiative comes from a patient with a complaint Criteria for Screening test Screening test must satisfy the criteria of - acceptability - repeatability - validity - simplicity - safety - rapidity - ease of administration - low cost 1. Acceptability - Considering that screening tests are applied on asymptomatic people in large numbers, a high rate of people cooperation is needed. Thus the tests should be acceptable to the people. In general, tests that are painful, discomfoing or embarrasing (eg. rectal or vaginal examinations) are not likely to be acceptable to the population in mass campaigns. 2. Repeatability (Precision or reproducibility) - means that the test must give consistent results when repeated more than once on the same individual or material under the same conditions. 3.Low cost - A screening should be inexpensive. As a screening test has to be applied on millions of people to identify a small percentage who have early disease or its precursors, an expensive test however good, cannot justify use of restricted financial resources that has to be used for fuher diagnostic workup and t/t of those screened on positives. 4. High safety margin - This is an attribute of any test, whether diagnostic or screening. Moresoever for screening as screening tests are to be applied on millions of asymptomatic people and any adverse effect would bring whole process into disrepute. iims IN/nee answers & explanations -- May 2007 5. Validity - It expresses the ability of a test to separate or distinguish those who have the disease from those who do not - Validity has two components - sensitivity & specificity - An ideal screening test should be both highly sensitive and highly specific. But this is seldom possible and a compromise has always to be made.

Social & Preventive Medicine

4811f36f-4846-4e80-ae5c-45fa6dafd801

World diabetes day is celebrated on ?

8th may

8th march

14th November

1" december

single

Ans. is 'c' i.e., 14th November8 May - World Red Cross Day8th March - International Women's Day14th November -/ World Diabetes Dayl' December - World AIDS Day

Social & Preventive Medicine

067b5e15-9b62-4272-a3d0-e594516950c5

Cataract is seen in following except:

Glucocorticoid administration

Rheumatoid arthritis

Hypoparathyroidism

Galactosemia

multi

Ans. is 'b' i.e. Rheumatoid arthritis Aetiological classification of cataract:Senile CataractDevelopmental or congenitalComplicated cataractTraumaticMetabolicDiabetes*Tetany (hypoparathyroidism)Hypoglycemia*Galactosemia*Galactokinase deficiency*Lowe's syndrome*Wilson's disease*Maternal infectionRubella*Toxoplasma*CMV*ToxicGlucocorticoids *Busulphan*Chlorambucil*Long acting miotics*SyndromesWerner's*Alport's*Rothmund*Downs*Radiation alDermatogenicAtopic dermatitis*Rothmund' s syndrome*Werner's syndrome*

Ophthalmology

Acquired Cataract

0216e1d4-bdf2-4681-946e-0559d4119abb

A 75-year-old woman presents with history of tripping and falling in the bathroom and unable to walk or bear weight on her left hip. On examination it was noted that her left lower limb was in an externally rotated position, hip was tender and active straight leg raising was not possible. The most possible diagnosis is:

Fracture neck of femur

Osteoarthritis hip

Dislocation of hip joint

Acetabular fracture

multi

Ans: A (Fracture neck of femur) Ref: Apley's System of Orthopaedics and Fractures, 9th Edition, P 847-848Explanation:Fracture Neck of FemurMost common site of fractures in the elderly.Common in women in the 8th and 9th decades.The association with osteoporosis is main underlying factor.Other risk factors include bone-losing or bone-weakening disorders such as osteomalacia, diabetes, stroke (disuse}, alcoholism and chronic debilitating disease.In addition, old people often have weak muscles and poor balance resulting in an increased tendency to fall.The fracture usually results from a simple fall; how ever, in very osteoporotic people, less force is required--perhaps no more than catching a toe in the carpet and twisting the hip into external rotation.Occasionally, stress fractures of the femoral neck occur in runners or military personnel.Not all hip fractures are so obvious. With an impacted fracture the patient may still be able to walk, and debilitated or mentally handicapped patients may not complain at all-even with bilateral fractures.

Orthopaedics

Fracture Neck of Femur

0cbbd32f-213b-47ee-a97b-3a29ecea28cd

Which one of the following is the most sensitive and specific screening test to detect breast cancer?

Regular X-ray

Self breast examination

Mammography

Regular biopsy

single

Ans. is 'c' i.e., Mammography Mammography is most sensitive and specific in detecting small tumors that are sometimes missed on palpation. Screening Test (s) Disease screened Papanicolaou (Pap) smear test Cervical cancer Breast self examination (BSE) Breast cancer Mammography Breast cancer Bimanual oral examination Oral cancer ELISA, RAPID, SIMPLE HIV (National AIDS Control Programme) Urine for Sugar, Random blood sugar Diabetes mellitus AFP (alpha-feto-protein) Developmental anomalies in fetus Digital rectal examination (DRE) Prostate cancer Prostate specific antigen (PSA) Prostate cancer Fecal occult blood test Colorectal cancer

Social & Preventive Medicine

9dc69f44-568b-473c-9a9f-603bfcacc599

Consider the following conditions - 1. Central diabetes insipidus, 2. Uncontrolled diabetes mellitus, 3. Mannitol infusion, 4. Post - obstructive diuresis. Which of the above result in solute diuresis?

1 and 2 only

1, 2 and 3

2, 3 and 4

1, 3 and 4

multi

Medicine

51caac51-a6aa-4398-93e1-7945d3f4082c

Drug of choice for central diabetes insipidus

Vasopressin

Desmopressin

Lypressin

Presselin

single

Ans. is'b'i.e., DesmopressinDesmopressin (intranasal) is the DbC for central DI.

Pharmacology

119ed07f-c029-4498-9f57-4e987ae04d1e

Most common cause of End stage renal disease is:

Diabetes

Hypertension

Chronic GN

Polycystic Kidney disease

single

Ref: Harrison's Principles of Internal Medicine. 18ed.Explanation:The dispiriting term end-stage renal disease' should not be used and is replaced by the term stage 5 CKD"The most frequent cause of CKD is diabetic nephropathy. most often secondary to type 2 diabetes melli- tus Ref: HarrisonLeading Categories of Etiologies of CKDDiabetic glomerular disease (MC Cause)GlomerulonephritisHypertensive nephropathyPrimary glomerulopathy with hypertensionVascular and ischemic renal diseaseAutosomal dominant polycystic kidney diseaseOther cystic and tubulointerstitial nephropathy

Medicine

Chronic Kidney Disease and Uremia

4452d3fb-b9fd-438d-b2d6-b70cb4fd4eb3

All are seen in cystitis EXCEPT:

Fever

Hematuria

Dysuria

Nocturia

multi

ANSWER: (A) FeverREF: Smith urology 17th ed page 206Acute cystitis refers to urinary infection of the lower urinary tract, principally the bladder.Acute cystitis more commonly affects women than men.Patients with acute cystitis present with irritative voiding symptoms such as dysuria, frequency, Nocturia and urgency,Low back and suprapubic pain, hematuria, and doudy/foul smelling urine are also common symptoms.Fever and systemic symptoms are rare.Urinalysis demonstrates WBCs in the urine, and hematuria may be present.Urine culture is required to confirm the diagnosis and identify the causative organism. However, when the clinical picture and urinalysis are highly suggestive of the diagnosis of acute cystitis, urine culture may not be needed.E. coli causes most of the acute cystitis. Other gram-negative (Klebsiella and Proteus spp.) and gram-positive (S. saprophyticus and enterococci) bacteria are uncommon pathogens.Diabetes and lifetime history of UTI are risk factors for acute cystitis.In general, those in whom acute cystitis developed do not usually require any extensive radiologic investigation (such as a voiding cystourethrogram), but those in whom pyelonephritis developed do.Choice of Antibiotics: 1st: TMP-SMX, 2nd: Fluoroquinolone, 1-3 days

Surgery

Miscellaneous (Bladder)

d6fb8c1d-f4df-4919-a430-9128b7df47e5

True statement about gallstones are all except:

Lithogenic bile is required for stone formation

May be associated with carcinoma gallbladder

Associated with diabetes mellitus

More common in males between 30-40 years of age

multi

Ans. (d) More common in males between 30-40 years of ageDiabetes mellitus and Gall stones:* Diabetes though not a direct risk factor for gall stones- the following factors in diabetes may increase the chance of getting Gall stones:# Increased Bile Cholesterol# Poor GB motility# Decreased Bile Acids

Surgery

Gall Bladder & Bile Ducts

442d95b9-95e9-4e93-accf-31bd5e2fc81a

Diabetes control is best monitored by -

Serum glucose

Post prandial blood glucose

HbA1c

HbA2c

single

Measurement of glycated hemoglobin (HbA1c) is the standard method for assessing long-term glycemic control. When plasma glucose is consistently elevated, there is an increase in nonenzymatic glycation of hemoglobin. This alteration reflects the glycemic history over the previous 2-3 months, because erythrocytes have an average life span of 120 days (glycemic level in the preceding month contributes about 50% to the HbA1c value). Measurement of HbA1c at the "point of care" allows for more rapid feedback and may therefore assist in adjustment of therapy. A rise of 1% in HbA1c corresponds to an approx average increase of 2 mmol/L (36 mg/dL) in blood glucose. Reference : page 2410 Harrison's Principles of Internal Medicine 19th edition

Medicine

Endocrinology

1aa45a13-94ca-4936-bde2-46b5527e91ee

Dopamine agonist used in diabetes

Metformin

Bromocriptine

Cabergoline

Vanadium salts

single

Bromocriptine and cabergoline are dopamine agonists but bromocriptine usage in type 2 diabetes is approved.It has an interesting mechanism of action by inhibiting the dopamine dip that causes in early morning leading to hyperglycemia. Ref: Goodman and Gillman 13th ed

Pharmacology

Endocrinology

517972b9-93be-4904-8025-4291e8fc4f1e

Screening is not recommended if -

Prevalence of disease is high

Life expectancy can be prolonged by early diagnosis

Diagnostic test should be available

Diseases with no latent period

single

Ans. is 'd' i.e., Disease with no latent period o The disease to be screened should fulfil the following criteria before it is considered suitable for screening:-The condition sougth should be an important health problem (in general, prevalence should be high).There should be a recognizable latent or early asymptomatic stage.The natural history of the conti ti on, including development from latent to declared disease, should be adequately understood (so that we ean know at what stage the process ceases to be reversible).There is a test that can detect the disease prior to the onset of signs and symptoms.Facilities should be available for confirmation of the diagnosis.There is an effective treatment.There should be an agreed-on policy concerning whom to treat as patients (e.g., lower ranges of blood pressure; border-line diabetes).There is good evidence that early detection and treatment reduces morbidity and mortality.The expected benefits (e.g., the number of lives saved) of early detection exceed the risks and costs.

Social & Preventive Medicine

Screening for Disease

cdc0feed-b89a-4fe7-b0f2-a6f41a583245

A 40-year-old obese man presents with intense pain in his left first metatarsophalangeal (MTP) joint for the past few hours. He has no history of trauma, fever, chills, and no previous similar episode. He has no history of renal disease or diabetes though he has been told he is "prediabetic." He does not recall any recent skin infections and no family members have had any reported staphylococcal infection. On examination he has a swollen, red, warm, tender first MTP joint on the left. Uric acid level is 9 mg/dL; serum creatinine is normal. What is the best treatment approach for this patient?

Start allopurinol immediately and titrate for a uric acid level below 6. Add colchicine if this is not effective within the first 24 hours.

Begin prednisone until symptoms subside.

Begin indomethacin. As the patient improves, reduce the dose to minimize gastrointestinal side effects.

Prescribe a narcotic until pain is under control.

multi

This patient is experiencing his first episode of acute gout. The first MTP joint is the most commonly affected, and 80% of acute gout attacks will be monoarticular. Predisposing conditions include trauma, surgery, starvation, high intake of beer and hard liquor (not wine), or diets high in meat and seafood. Certain medications also increase the chances of acute gout including thiazide and loop diuretics and even the initiation of uric acid lowering drugs such as allopurinol and uricosuric agents. Appropriate initial treatment must be tailored to the patient and their comorbidities. The patient in this question has no contraindication, so a potent NSAID (indomethacin) can be used and is likely to be highly effective. Other acceptable alternatives would have been to start colchicine immediately or oral prednisone in relatively high doses. Since this patient is "prediabetic," steroids may result in overt hyperglycemia and hence would not be the first choice. Allopurinol should not be started until the acute attack has been controlled by anti-inflammatory regimens. All agents that lower uric acid levels (either allopurinol or uricosuric agents) can cause worsening of joint pain, probably by mobilizing uric acid microcrystals previously deposited in the synovial membrane. While narcotics may lessen the pain, they are less effective than anti-inflammatories. Referring the patient to a rheumatologist is unnecessary and would leave the patient in pain and suffering in the meantime.

Medicine

Miscellaneous

6d53b647-13d0-4bd6-8d95-6f11c4225532

Differential diagnosis of Hyperemesis gravidarum:

Gastritis

U.T.I

Reflux oesophagitis

All

multi

Ans. is a, b and c Nausea and vomiting of pregnancy commonly termed morning sickness' is a normal phenomenon in pregnancy, occurring in about 70% of all pregnancies. in most women, it is limited to the first trimester. but a few may continue to have symptoms throughout pregnancy. Hyperernesis gravidarum is the other end of the spectrum characterised by severe nausea and intractable vomiting sufficient to interfere with nutrition. Risk Factors : - Maternal age > 35 years High body weight. Nulliparity H. mole - Cigarette smoking Twin pregnancy - Fetal loss Positive family history - Unplanned pregnancy Clinical features are due to : -- Dehydration Stareation Ketoacidosis Vomiting associated with Pregnancy (unr-lated to pregnancy) Medical W * intestinal infestation * Urinary tract infection * Hepatitis/Pancreatitis * Keto-acidosis of diabetes * Uraemia * CNS disorder Surgical * Appendicitis *Peptic ulcer reflux *Intestinal obstruction * Cholecystitis/Cholelithiasis Gynaecological * Twisted ovarian tumour * Red degeneration of fibroid Management : Mild to moderate Nausea and Vomiting of Pregnancy - usually needs no treatment except reassurance and frequent small meals. Vitamin B5 alone or with doxylamine is safe and can be considered. Vomiting associated with Pregnancy (unr-lated to pregnancy) Medical W * intestinal infestation * Urinary tract infection * Hepatitis/Pancreatitis * Keto-acidosis of diabetes * Uraemia * CNS disorder Surgical * Appendicitis * Peptic ulcer reflux * Intestinal obstruction * Cholecystitis/Cholelithiasis Gynaecological * Twisted ovarian tumour * Red degeneration of fibroid

Gynaecology & Obstetrics

782a8699-5d7e-4d6b-b96c-69d40c9d41c1

All of the following drugs can be used for diabetes insipidus, except :

Amiloride

Furosemide

Chlorpropamide

Carbamazepine

multi

Pharmacology

513071f0-e06a-467d-b659-deef5ec807cd

Hyperkalaemia can occur in all, except-

Insulin deficiency

Metabolic acidosis

Acute renal failure

Cushing's syndrome

multi

Causes of hyperkalemia are: I Pseudohyperkalemia A. Cellular efflux; thrombocytosis, erythrocytosis, leukocytosis, in vitro hemolysis B. Hereditary defects in red cell membrane transpo II. Intra- to extracellular shift A. Acidosis B. Hyperosmolality; radiocontrast, hypeonic dextrose, mannitol C. b2-Adrenergic antagonists (noncardioselective agents) D. Digoxin and related glycosides (yellow oleander, foxglove, bufadienolide) E. Hyperkalemic periodic paralysis F. Lysine, arginine, and e-aminocaproic acid (structurally similar, positively charged) G. Succinylcholine; thermal trauma, neuromuscular injury, disuse atrophy, mucositis, or prolonged immobilization H. Rapid tumor lysis III. Inadequate excretion A. Inhibition of the renin-angiotensin-aldosterone axis; | risk of hyperkalemia when used in combination 1. Angiotensin-conveing enzyme (ACE) inhibitors 2. Renin inhibitors; aliskiren (in combination with ACE inhibitors or angiotensin receptor blockers ) 3. Angiotensin receptor blockers (ARBs) 4. Blockade of the mineralocoicoid receptor: spironolactone, eplerenone, drospirenone 5. Blockade of the epithelial sodium channel (ENaC): amiloride, triamterene, trimethoprim, pentamidine, nafamostat B. Decreased distal delivery 1. Congestive hea failure 2. Volume depletion C. Hyporeninemic hypoaldosteronism 1. Tubulointerstitial diseases: systemic lupus erythematosus (SLE), sickle cell anemia, obstructive uropathy 2. Diabetes, diabetic nephropathy 3. Drugs: nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase 2 (COX2) inhibitors, b-blockers, cyclosporine, tacrolimus 4. Chronic kidney disease, advanced age 5. Pseudohypoaldosteronism type II: defects in WNK1 or WNK4 kinases, Kelch-like 3 (KLHL3), or Cullin 3 (CUL3) D. Renal resistance to mineralocoicoid 1. Tubulointerstitial diseases: SLE, amyloidosis, sickle cell anemia, obstructive uropathy, post-acute tubular necrosis 2. Hereditary: pseudohypoaldosteronism type I; defects in the mineralocoicoid receptor or the epithelial sodium channel (ENaC) E. Advanced renal insufficiency 1. Chronic kidney disease 2. End-stage renal disease 3. Acute oliguric kidney injury F. Primary adrenal insufficiency 1. Autoimmune: Addison's disease, polyglandular endocrinopathy 2. Infectious: HIV, cytomegalovirus, tuberculosis, disseminated fungal infection 3. Infiltrative: amyloidosis, malignancy, metastatic cancer 4. Drug-associated: heparin, low-molecular-weight heparin 5. Hereditary: adrenal hypoplasia congenita, congenital lipoid adrenal hyperplasia, aldosterone synthase deficiency 6. Adrenal hemorrhage or infarction, including in antiphospholipid syndrome

Medicine

Fluid and electrolytes

26635de7-8895-4fa5-8603-5d18634abf01

Which of the following is a contraindication to the use of Beta Blockers:-

Glaucoma

Tachycardia

Bronchial asthma

Hypeension

single

* Contraindication of Blocker:- Asthma AV Block Acute CHF Diabetes Mellitus * ss Blocker uses:- Hypeension Migraine Hypehyroidism Angina pretoirs MI

Pharmacology

NEET 2019

028c801f-3796-45fb-b81f-65ac6c1a02fc

MgSO4 is contraindicated in eclampsia if following occurs during treatment EXCEPT -

Urine output is <30 ml/hr

Respiratory rate < 16

Diastolic BP <90

Knee jerk absent

multi

(Respiratory rate < 16) (234-35 Dutta 7th; Internet)Magnesium sulphate is a smooth muscle relaxant. Reduction or loss of tendon reflexes precedes respiratory depression, and should be immediately noted.Deep Tendon Reflexes Elicit, grade, and record: 15 minutes during the first 2 hours of therapy, then hourly thereafterContraindications to Magnesium Sulfate Usea. Myasthenia gravisb. Heart block/recent myocardial infarctionc. Severe renal diseased. Signs of magnesium toxicityThe consultant should be alert if the woman experiences any of the following signs/svmptoms:* Significant changes in BP from baseline values* Tachycardia or bradycardia* Respiratory rate < 14 or >24* Oxygen saturation <95%* Changes in breath sounds suggestive of pulmonary edema* Changes in level of consciousness or neurologic status* Absent DTRs* Urinary output <30 mL/hr* Any concerns about the fetal heart rate pattern (Classes II and III tracings)Magnesium Sulfate can cause fetal abnormalities when administered beyond 5 to 7 days to pregnant women.There are retrospective epidemiological studies and case reports documenting fetal abnormalities such as hypocalcemia, skeletal demineralization, osteopenia and other skeletal abnormalities with continuous maternal administration of Magnesium sulfate for more than 5 to 7 days.* Magnesium sulphate is the drug of choice in Eclampsia also used in Torsades de points.* The therapeutic level of serum magnesium is 4 - 7 mEq/L* Benefits:(i) It controls fits effectively without any depression effect to the mother or the infant.(ii) Reduced risk of recurrent convulsions.(iii) Significantly reduced maternal death rate (3%).(iv) Reduced perinatel mortality.* Repeat injections are given only(i) Knee Jerks are present.(ii) Urine output exceeds 30 ml/hour(iii) Respiration rate is more than 12 per minute.* Magnesium sulfate is useful as an additional bronchodilator in patients with acute severe asthma (1045 - Good man and Gillman 12th)* Contraindication of magnesium sulfate in a pregnancy with late onset diabetes mellitus and sensory deafness due to mitrochondrial myopathy.Adverse effect of magnesium sulfate.* Diaphoresis* Depressed reflexes* Facial flushing* Reduced heart rate* Hypotension* Circulatory collapse * Respiratory depression

Gynaecology & Obstetrics

Miscellaneous (Gynae)

c220d687-9607-474a-a5d5-dfa2e99087f0

DOC for nephrogenic diabetes insipidus:

Mannitol

Spironolactone

Thiazides

Demeclocycline

single

Ref: Goodman & Gillman's 13th ed. P 466* Nephrogenic DI may be congenital or acquired. Causes can be:# Hypercalcemia, hypokalemia, post obstructive renal failure, Li+, foscarnet, clozapine, demeclocycline, and other drugs can induce nephrogenic DI.* Thiazide diuretics reduce the polyuria of patients with DI and often are used to treat nephrogenic DI.* DOC for central diabetes insipidus: Desmopressin (V2 receptor agonist)* DOC for nephrogenic diabetes insipidus: Thiazide diuretics.* DOC for lithium induced diabetes insipidus: Amiloride

Pharmacology

G.I.T

64cdae09-be6d-42d6-990a-d170d4225895

Low glycemic index is classified as value less than:

25

45

55

65

single

Concept of glycemic index has utility in management of diabetes and obesity. Classification GI range Example Low GI 55 or less Most fruits and vegetables except potatoes and water melon, pasta beans, lentils Medium GI 56-69 Sucrose, brown rice, basmati rice High GI 70 or more Corn flakes, white bread, candy bar Ref: Park 22nd edition, page 568

Social & Preventive Medicine

d698e4de-d3b9-4f39-b8a2-1668e82b09e5

Which is the principle for management of diabetic foot?

Control of DM

Topical antibiotics is paramount

Protection of the other limb

Early amputation

single

Ans: a. (Control of DM)Ref: Cuschieri, 4th ed. pg. 783The treatment of diabetic foot should be multi disciplinary involving vascular surgeon, diabetologist, and chiropodist. The main pathophysiology of diabetic foot involves a combination of neuropathy, infection and ischaemia. The goal of management should be control of blood glucose and health education directed at preventing foot trauma.Prolonged antibiotic therapy should be used in the event of osteomyelitis. Prompt surgical drainage of abscesses should be undertaken.In summary, the treatment of diabetic foot should involve:1. Adequate control of blood glucose2. Prompt control of sepsis3. Vascular assessment4. Debridement including minor amputations. Major amputations should be undertaken for severe spreading uncontrollable limb infection threatening life, or the limb is severely ischaemic. Once one limb has been amputated, there is increased risk of amputation of the other limb, and the patient's survival rate is only 30%. Topical antibiotics are not of much benefit in the management of diabetic foot.Though both options, a and c are correct, option a (control of diabetes) seems to be the better answer.

Surgery

Wounds, Tissue Repair & Scars

d5b34a55-b203-43d5-b475-0a2457c91030

Most important side effect of insulin:

Hypoglycaemia

Lipodystrophy

Insulin resistance

Antibodies to insulin

single

Ans: a (Hypoglycaemia) no referance needed for this one !!!CAUSES OF HYPOGLYCAEMIAFasting (Postabsorptive) Hypoglycemia DrugsEndogenous hyperinsulinismEspecially insulin, sulfonylureas, ethanolInsulinomaSometimes quinine, pentamidineOther beta cell disordersRarely salicylates, sulfonamides, othersInsulin secretagogue (sulfonylurea)Critical illnessesAutoimmune (autoantibodies to insulinHepatic, renal, or cardiac failureor the insulin receptor)SepsisEctopic insulin secretionInanitionDisorders of infancy or childhoodHormone deficienciesTransient intolerance of fastingCortisol, growth hormone, or bothCongenital hyperinsulinismGlucagon and epinephrineInherited enzyme deficiencies(in insulin -deficient diabetes) Non-beta-cell tumors Reactive (Postprandial) HypoglycaemiaAlimentary (postgastrectomy) hypoglycaemiaNoninsulinoma pancreatogenous hypoglycaemia syndromeIn the absence of prior surgeryFollowing Roux-en-Y gastric bypass.Other causes of endogenous hyperinsulinismHereditary fructose intolerance, galactosaemiaIdiopathic

Pharmacology

Endocrinology

29c81ebc-ef77-4793-8f00-5e281b9ae6b7

A 58-year-old man has the sudden onset late one evening of severe pain in his left great toe. There is no history of trauma. On examination there is edema with erythema and pain on movement of the left 1st metatarsophalangeal joint, but there is no overlying skin ulceration. A joint aspirate is performed and on microscopic examination reveals numerous neutrophils. Over the next 3 weeks, he has two more similar episodes. On physical examination between these attacks, there is minimal loss of joint mobility. Which of the following laboratory test findings is most characteristic for his underlying disease process?

Hyperglycemia

Positive antinuclear antibody

Hyperuricemia

Hypercalcemia

single

Many patients with gout will have hyperuricemia, but not all. The big toe is the most common joint involved with gout. Acute gouty attacks are associated with intense pain from acute inflammation. Incorrect 1. Hyperglycemia is a feature of diabetes mellitus, which is associated with peripheral vascular disease that increases the risk for foot ulcerations and osteomyelitis. Incorrect 2. The arthralgias common to many autoimmune diseases with a positive ANA, such as systemic lupus erythematosus, are not usually associated with joint swelling, redness, or deformity. Incorrect 4. There can be bone luceny with hyperparathyroidism, but the joints are not greatly affected, nor is there swelling or redness.

Unknown

91dd97ae-95ed-4c64-ab7a-47f1dab7a522

Acalculous cholecystitis is caused by all except

DM

TPN

Leptospirosis

Estrogen therapy

multi

Causes of Acalculous cholecystitis Common causes Elderly and critically ill patients after trauma Burns Longterm TPN Major operations(Abdominal aneurysm repair and cardiopulmonary bypass) Diabetes mellitus Uncommon causes Vasculitis Obstructing GB adenocarcinoma GB torsion Parasitic infestation Unusual bacterial infection - Leptospira, streptococcus, salmonella , Vibrio cholera Ref: Harrison's 19th edition Pgno : 2081

Anatomy

G.I.T

23a11dfe-527c-4b6d-b15e-fa40831c95bc

Arrange the following causes of NCD deaths as per decreasing order of frequency? A. Cancers B. Cardiovascular diseases C. Diabetes D. Respiratory diseases

A>D>C>B

D>A>B>C

B>A>D>C

C>B>D>A

single

The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. The leading causes of NCD deaths in 2016 were Cardiovascular diseases ( 44% of all NCD deaths) Cancers (22% of all NCD deaths) Respiratory diseases, including asthma and chronic obstructive pulmonary disease (9% of all NCD deaths). Diabetes caused another 1.6 million deaths.

Social & Preventive Medicine

NCDs: CHD, HTN, DM, RF, Cancers, Obesity, Blindness

af81185b-71bb-4ec0-9784-a1219706d38a

As per ACOG - 2001 criteria to diagnose "gestational diabetes" using GTT is plasma glucose at 2 hr more than____ mg/dL:

180

155

140

126

single

Ans-B (Ref. William's Obstetrics 22nd /Table 52 - 4).American College of Obstetricians and Gynecologists 2001 Criteria for Diagnosis of Gestational table: DiabetesUsing the 100-g Oral Glucose Tolerance Test: Plasma/ Serum Carpenter and CoustanNational Diabetes Plasma Data GroupStatusmg/dLmmol/Lmg/dLmmol/LFasting955.31055.81 hr18010.019010.62 hr1558.61659.23 hr1407.81458.0

Unknown

e9a97840-5bad-4fd2-9ac2-99bcc42c0818

In starvation, there is ketosis due to ?

Decreased acetyl CoA

Increased b-oxidation

Decreased lipolysis

Decreased fatty acid

single

Ans. is 'b' i.e., Increased b-oxidationStarvation is characterized by decreased insulin : glucagon ratio.This causes :?i) Increased lipolysis - More FFAs for ketogenesis.ii) Increased fi-oxidation - Increased ketogenosis.iii) Decreased oxaloacetate - Acetyl CoA is utilized in ketogenesis.Regulation of ketogenesisKetogenesis is regulated at three levels:?1) Factors regulating mobilization of fatty acids from adipose tissues (i.e. lipolysis):- Free fatty acids, the precursors of ketone bodies, arise from lipolysis of triglycerides in adipose tissue. Hence, factors which enhance lipolysis (e.g. glucagon) stimulate ketogensis by providing more free fatty acids. Conversely, factors that inhibit lipolysis (e.g. insulin) inbibit ketogenesis.2) Factors regulating b-oxidation of fatty acids:- After uptake by liver, FAAs are either (i) b-oxidized to CO, or ketone bodies, or (ii) esterified to triacylglycerol. Carnitine acetyl transferase-I (CAT-I) regulates the b-oxidation of fatty acid and therefore the production of staing materials of ketogenesis i.e. acetylCoA and acetoacetyl-CoA (The remainder of fatty acids which do not enter b-oxidation, are estesified). Activity of CAT-1 is high in starvation and diabetes leading to increased b-oxidation of fatty acids and increased ketogenesis. CAT-1 activity is low in well fed state, resulting in decreased 13-oxidation and ketogenesis. This regulation is governed by Malonyl CoA, which is an allosteric inhibitor of carnitine acetyl transferase-1: CAT-1 (or carnitine palmitoyl transferase-1: (CPT-1). Malonyl CoA is synthesized by acetyl CoA carboxylase. Activity of acetyl CoA carboxylase is high in well fed state due to increase in insulin/ glucagon ratio, which inturn results in increased formation of malonyl-CoA. Malonyl-CoA inhibits CAT-I (CPT-I) leading to decreased b-oxidation and ketogenesis. Hence, esterification of fatty acids is increased. Conversely, during starvation (and diabetes) insulin/glucagon ratio is decreased which results in decreased activity of acetyl CoA carboxylase and decreased production of malonyl-CoA, releasing the inhibition of CAT-I (CPT-I). This results in increase b-oxidation of fatty acids and ketogenesis.3) Factors regulating the oxidation of acetyl CoA:- The acetyl-CoA formed in b-oxidation is oxidized in the citric acid cycle, or it enters the ketogenesis to form ketone bodies. When oxaloacetate concentration is low, little acetyl-CoA enters the TCA cycle and ketogenesis is oured (first reaction of TCA cycle inolves oxaloacetate, where it combines with acetyl-CoA to form citrate). Concentration of oxalaceatate is lowered if carbohydrate is unavailable or improperly utilized, e.g. in fasting and in diabetes.

Biochemistry