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Transmission of S. aureus generally occurs by direct contact or by spread of heavy particles over a distance of 6 ft or less. Spread by fomites is rare. Heavily colonised individuals and perianal carriers are particularly effective disseminators. Neonates are extremely susceptible to staphylococci; the nasopharynx, skin, perineum, and umbilical stump are the most common sites of colonisation. Autoinfection is common, and minor infection (e.g., styes, pustules, paronychia) may be the source of disseminations. Handwashing between contacts with patients decreases the spread of staphylococci from patient to patient. Older children and adults are more resistant than the neonate to colonisation. Prevention: Staphylococcal infection is transmitted primarily by direct contact. Strict attention to handwashing techniques is the most effective measure for preventing the spread of staphylococci from one individual to another . Use of a detergent containing an iodophor, chlorhexidine, or hexachlorophene is recommended. In hospitals or other institutional settings, all persons with acute staphylococcal infections should be isolated until they have been treated adequately. There should be constant surveillance for nosocomial staphylococcal infections within hospitals. Infectious disease control measures may reduce the spread of infection. Explanation A. Give antibiotics to all other patients in the ward is not the best method. B. Fumigate the ward is a far fetched option. C. Disinfect the ward with sodium hypochlorite Asking for too much. D. Practice proper hand washing is the best option. Comments A micro question from Pharmac/Nelson as well as many surgery books. Tips Look at the word "best" in the question. 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Succimer is indicated for the treatment of lead poisoning in children with blood lead concentrations above 45 mcg per decilitre. Succimer also is indicated to treat lead toxicity in adults. Use of succimer should be accompanied by identification and removal of the source of lead exposure. Comments Desferrioxamine is relatively nontoxic. Occasional cataracts, deafness, and local skin reactions, including urticaria, occur. Skin reactions can usually be managed with antihistamines. Negative iron balance can be achieved, even in the face of a high transfusion requirement, but this alone does not prevent long-term morbidity and mortality in chronically transfused patients. Irreversible end-organ deterioration develops at relatively modest levels of iron overload, even if symptoms do not appear for many years thereafter. To obtain a significant survival advantage, chelation must begin before 5 to 8 years of age. Tips 2 questions have been asked from thalassaemia in this exam, and this proves how important the subject is. KD Tripathi 5th Edition (Aug 2003) gives most of the new drugs !! 221. Haemorrhage secondary to heparin administration can be best corrected by administration of: A. Vitamin K. B. Whole blood. C. Protamine. D. Ascorbic acid. Answer: C (Protamine) Ref: KDT 5th edn, 564 & 4th edn, 603; Harrison 15th, Part 6 - Sec 3 - Chap 118; Katzung 7th edn, 551 Quality: Spotter Status: Repeat QTDF: All books Discussion The major complication of unfractionated heparin therapy is bleeding, especially from surgical sites and into the retroperitoneum. Aspirin or aspirin-containing drugs impair platelet function. Thus, intramuscular injections in patients on both heparin and an antiplatelet drug may cause significant bleeding. Heparins anticoagulant effect can be rapidly reversed by the administration of protamine sulphate. However, this is usually not necessary, since reduction or omission of a heparin dose usually improves haemostasis and stops bleeding. Thrombocytopenia occurs in ~10% of recipients and is usually mild, with the platelet count falling to 50,000 to 100,000/uL. Thrombocytopenia is more common in patients receiving heparin derived from beef lung as opposed to porcine intestinal mucosa. Low-molecular-weight heparin (LMWH) is less likely to cause either thrombocytopenia or bleeding. However, antibodies arising from exposure to unfractionated heparin often crossreact with LMWH. Thus, LMWH cannot usually be used to treat patients with established thrombocytopenia. Protamine is indicated in the treatment of severe heparin overdose resulting in haemorrhage. It is indicated to neutralise heparin that is administered during extracorporeal circulation in arterial and cardiac surgery or dialysis procedures; also, it may be used to neutralise the haemorrhagic effects following overdose of the, LMWH enoxaparin. Transfusion of whole blood or fresh frozen plasma may also be required to replace lost volume if haemorrhaging has been severe; this may dilute, but will not neutralise, the effects of heparin. Explanation A. Vitamin K is a procoagulant, that is concerned with Warfarin and not heparin. B. Whole blood is for volume loss and cannot correct bleeding. C. Protamine is the correct drug 1 mg for 100 U of heparin. It is a strongly basic compund and is obtained from the sperm of certain fish. D. Ascorbic acid is vitamin C, and can be given for gum bleeding if it is due to scurvy. Comments Obviously, there are two problems in heparin overdose. 1. AnticoagulationBleeding 2. 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No active management as heparin action disappears in few hours. 2. Protamine if there is still bleeding. ALL Medical and Pharmacological Books say this: Blood loss is managed by: 1. Whole blood transfusionTripathi as above The question asks management of bleeding... the answer is obviously Protamine. Tips Heparin is an enzyme activator, whereas most of the drugs we use are enzyme inhibitors. Another enzyme activator is P2AM. Forskalin activates adenylate cyclase, etc. 222. Bacitracin acts on: A. Cell wall B. Cell membrane. C. Nucleic acid. D. Ribosome. Answer: A (Cell wall) Ref: Katzung, 7th edn, 739; KDT 5th edn, 693 & 4th edn, 672 to 673 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this. Discussion Bacitracin acts by inhibiting cell wall synthesis at a step earlier than that inhibited by penicillins. It is a polypeptide and a topical agent. It is got from Bacillus subtilis. Explanation A. Bacitracin acts on the cell wall. B. Antifungals act on cell membrane. C. Drugs like ciprofloxacin act on nucleic acid. D. Drugs like tetracycline act on the ribosome. Comments The various drugs acting in the cell wall, however, act at different levels. Tips As always the question are from Anti group of drugs; Anti Epilepsy, Anticholinergics Antituberculous, Anti-leprosy, Antimalarial, Antifungal, Antibiotics, and Anti-histaminics. 223. All of the following drugs act on cell membrane, except: A. Nystatin. B. Griseofulvin. C. Amphotericin B. D. Polymixin B. Answer: B (Griseofulvin) Ref: KDT 5th edn, 693 & 4th edn, 672 to 673 & 774 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this. Discussion Cell wall synthesis inhibition Penicillins Cephalosporins Cycloserine Vancomycin Bacitracin Cell membrane leakage Poly peptides: Polymyxins, Poly peptides: Colistin Polyenes: Amphotericin B, Polyenes: Nystatin, Polyenes: Hamycin Protein synthesis inhibition Tetracyclines Chloramphenicol Macrolides-erythromycin Clindamycin mRNA misreading Aminoglycosides DNA gyrase inhibition Fluroquinolones DNA function inhibition Metronidazole, Rifampicin DNA synthesis inhibition Acyclovir, Idoxuridine, Ziovudine Intermediary metabolism inhibition Sulphonamides, Trimethoprim Pyrimethamine Ethambutol PAS Explanation A. Nystatin [Katzung-786] produces micropores in the fungal cell membrane. B. Griseofulvin [Katzung-785] interferes with mitosis. C. Amphotericin B [Katzung-780] produces micropores in the fungal cell membrane. D. Polymyxin B [Katzung-804] produces pseudopores in the bacterial cell membrane. Comments Mechanism of action of antibiotics is a favoured topic. Tips Read the classification in Page 672 to 673 KDT 4th Edition. 224. The most effective drug against M. leprae is: A. Dapsone. B. Rifampicin. C. Clofazamine. D. Prothionamide. Answer: B (Rifampicin) Ref: Harrisons, 15th edn, 1039; KDT 5th edn, 711 & 4th edn, 766 Status: Repeat QTDF: KDT Discussion Established agents used to treat leprosy include: 1. dapsone (50 to 100 mg/d), 2. clofazimine (50 to 100 mg/d, 100 mg three times weekly, or 300 mg monthly), and 3. rifampin (600 mg daily or monthly). Of these drugs, only rifampin is bactericidal. The sulphones (folate antagonists), the foremost of which is dapsone, were the first antimicrobials found to be effective for the treatment of leprosy and are still the mainstay of therapy. With sulphone treatment, skin lesions resolve and numbers of viable bacilli in the skin are reduced. Although primarily bacteriostatic, dapsone monotherapy results in only a 10% resistance-related relapse rate; after 18 years of therapy and subsequent discontinuation, only another 10% of patients relapse, developing new, usually asymptomatic, shiny, histoid nodules. Dapsone is generally safe and inexpensive. Individuals with glucose-6-phosphate dehydrogenase deficiency who are treated with dapsone may develop severe haemolysis; those without this deficiency also have reduced red cell survival and a haemoglobin decrease averaging 1 g/dL. Dapsones usefulness is limited occasionally by allergic dermatitis and rarely by the sulphone syndrome (including high fever, anaemia, exfoliative dermatitis, and a mononucleosis-type blood picture). It must be remembered that rifampin induces microsomal enzymes, necessitating increased doses of medications such as glucocorticoids and oral birth control regimens. Clofazimine is often cosmetically unacceptable to light-skinned leprosy patients because it causes a red-black skin discolouration that accumulates, particularly in lesional areas, and makes the patients diagnosis obvious to members of the community. Other antimicrobial agents active against M. leprae in animal models and at the usual daily doses used in clinical trials include ethionamide/prothionamide; the aminoglycosides streptomycin, kanamycin, and amikacin (but not gentamicin or tobramycin); minocycline; clarithromycin; and several fluoroquinolones, particularly ofloxacin. Next to rifampin, minocycline, clarithromycin, and ofloxacin appear to be most bactericidal for M. leprae, but these drugs have not been used extensively in leprosy control programmes. Explanation A. Dapsone is the mainstay. B. Rifampicin is the most effective. C. Clofazamine is also used. D. Prothionamide, a congener of ethionamide that is not available in the United States, has pharmacologic properties similar to those of ethionamide and is widely used throughout the world. Comments Rifampicin is most effective as it is cidal, Dapsone is the mainstay. Tips While ethionamide (250 mg/d) has not been approved by the FDA for the treatment of leprosy, it is sometimes used in the United States in combination with rifampin (600 mg/d) to treat dapsone-resistant leprosy in patients who cannot accept the skin-depigmentation effect of clofazimine. Because resistance to ethionamide develops quickly when the drug is used alone, it must be used with other effective agents. 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Explanation A. Desferioxamine is poorly absorbed from GIT, but parenteral Desferioxamine is the chelating agent of choice. B. Deferiprone is a recently introduced drug, which is an orally active iron chelator, meant as an alternative to intravenous desferioxamine. Though it can be given orally, it is not as effective as Desferioxamine C. Intramuscular EDTA is an anticoagulant. Only calcium EDTA is a chelator of lead and heavy metals. 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The heart contraction is induced by a conformational change of cTnC triggered by the binding of calcium ions which are released from the sarcoplasmic reticulum. The conformational change of cTnC allows myosin to interact with actin filaments. Subsequently, the heart contracts as the filaments glide past each other. Knowledge of the three-dimensional structure of cTnC and its induced conformational changes at atomic resolution provide new means for understanding the basic events in the heart contraction. This knowledge is also of applied importance. In a number of cases, impaired heart functions can be alleviated by drug molecules designed to make troponin C more prone to a conformational change. These drugs which increase the calcium sensitivity are designated calcium sensitisers. It would be most useful for further development of these pharmaceuticals to be able to demonstrate the drug binding and its consequences to the conformation and dynamics of cTnC. Considering the fundamental role of cardiac troponin C in the heart function and the possibilities to modulate the function by pharmaceuticals a study of cTnC by methods of structural biology is most interesting and useful. The three-dimensional structure of cTnC should be determined in complex with relevant motifs of TnI. In addition, deeper insight into the structure-function relationship should be gained by a molecular dynamics study. A new calcium sensitiser drug levosimendan was discovered by calcium dependent affinity chromatography on a troponin complex column (Haikala et al., 1992). The screening was based on a hypothesis that calcium sensitisers bind in the hydrophobic patch formed in the regulatory domain of TnC following a calcium induced conformational change (Ovaska and Taskinen, 1991). It was recently shown that the new calcium sensitiser drug levosimendan binds to human cardiac troponin C (Pollesello et al., 1994). Tips Newer drugs are being asked with increased frequency these days. Go through the last few pages of Sure Success in PG (big book) by Ram Gopal and also the web site given above. Look in at www.rxpgonline.com 219. All of the following are useful intravenous therapy for hypertensive emergencies, except: A. Fenoldopam. B. Urapidil C. Enalapril D. Nifedipine. Answer: C (Enalpril) Ref: Harrisons, 15th, 1424 and Chapter 244; KDT 5th edn, 451 Enalapril Action is slower & 4th edn, 21(Enalapril) 136(Urapidil), 206 Table 13.1(Enalapril) Quality: Thinker Status: New QTDF: Harrison, KDT Discussion Note two words in the question: 1. Are useful (not used!! It is question of principles rather than application) 2. Emergencies Prodrugs are drugs that are by themselves inactive and have to be activated by conversion in the body. Such drugs cannot be given in emergencies as they need some time to act. In the list given in Page 21 KDT 4th Edition, it is given that Enalapril has to be converted into Enalaprilat to be active. Hence, it is very obvious that Enalaprilat and not Enalapril that is useful. Of the ACE Inhibitors only Captopril and Lisinopril are per se active. Others have to be biotransformed to become active. Explanation A. Fenoldopam is a rapid-acting vasodilator with agonist effects on dopamine D 1-like receptors, and only moderate affinity for the alpha 2-adrenergic receptors. Fenoldopam is a racemic mixture, with the R-isomer having an approximate 250-fold higher affinity for D 1-like receptors than the S-isomer. Fenoldopam has no agonist effect on presynaptic D 2-like dopamine receptors or on alpha- or beta-adrenergic receptors, and does not appear to affect angiotensin-converting enzyme activity. B. Urapidil is a selective alpha 1 blocker like Indoramine. C. Enalapril is a ACE Inhibitor, and is not useful in emergencies. D. Nifedipine is useful in emergencies. Comments Well, there are sufficient journals sites in internet to show that Nifedipine IV is used. See this if you are a doubting Thomas http://pharmacy.creighton.edu/pha443/didactic_content/ivbolus/PDF/pkin04.pdf Tips Sometimes the question setter wants to find whether we know a basic simple fact. At that time, the wordings will be very flexible. Another example in this same AIPG 2003 Paper is the question on Haemophilia. 220. The most appropriate drug used for chelation therapy in beta thalassaemia major is: A. Oral desferrioxamine. B. Oral deferiprone. C. Intramuscular EDTA. D. Oral Succimer. Answer: B (Oral deferiprone) Ref: OP Ghai, 5th edn, 99; KDT 5th edn, 815; Harrison 15th, 673 Chapter 106 Quality: Reader Status: New QTDF: Harrison Discussion Chronic blood transfusion can lead to blood-borne infection, alloimmunisation, febrile reactions, and lethal iron overload. A unit of packed RBCs contains 250 to 300 mg iron (1 mg/mL). The iron assimilated by a single transfusion of two units of packed RBCs is thus equal to a 1- to 2-year intake of iron. Iron accumulates in chronically transfused patients because no mechanisms exist for increasing iron excretion; an expanded erythron causes especially rapid development of iron overload because accelerated erythropoiesis promotes excessive absorption of dietary iron. Vitamin C should not be supplemented because it generates free radicals in iron excess states. Patients who receive >100 units of packed RBCs usually develop haemosiderosis. The ferritin level rises, followed by early endocrine dysfunction (glucose intolerance and delayed puberty), cirrhosis, and cardiomyopathy. Liver biopsy shows both parenchymal and reticuloendothelial iron. Newer methods for assessing hepatic iron such as the superconducting quantum-interference device (SQUID) are accurate but not widely available. Cardiac toxicity is often insidious. Early development of pericarditis is followed by dysrhythmia and pump failure. The onset of heart failure is ominous, often presaging death within a year. The decision to start long-term transfusion support should be accompanied by therapy with iron-chelating agents. The only approved and available iron chelator, desferrioxamine (Desferal), is expensive and poorly absorbed from the gastrointestinal tract (GIT). Its iron-binding kinetics require chronic slow infusion via a metering pump. The constant presence of the drug improves the efficiency of chelation and protects tissues from occasional releases of the most toxic fraction of iron-low-molecular-weight iron-which may not be sequestered by protective proteins. Oral iron-chelating agents such as deferriprone showed initial promise, but long-term trials have raised serious doubts about their efficacy and safety. Explanation A. Desferrioxamine is poorly absorbed from GIT, but parenteral Desferrioxamine is the chelating agent of choice. B. Deferiprone is a recently introduced drug, which is an orally active iron chelator, meant as an alternative to intravenous desferrioxamine. Though it can be given orally, it is not as effective as Desferrioxamine C. Intramuscular EDTA is an anticoagulant. 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However, this is usually not necessary, since reduction or omission of a heparin dose usually improves haemostasis and stops bleeding. Thrombocytopenia occurs in ~10% of recipients and is usually mild, with the platelet count falling to 50,000 to 100,000/uL. Thrombocytopenia is more common in patients receiving heparin derived from beef lung as opposed to porcine intestinal mucosa. Low-molecular-weightheparin (LMWH) is less likely to cause either thrombocytopenia or bleeding. However, antibodies arising from exposure to unfractionated heparin often crossreact with LMWH. Thus, LMWH cannot usually be used to treat patients with established thrombocytopenia. Protamine is indicated in the treatment of severe heparin overdose resulting in haemorrhage. It is indicated to neutralise heparin that is administered during extracorporeal circulation in arterial and cardiac surgery or dialysis procedures; also, it may be used to neutralise the haemorrhagic effects following overdose of the, enoxaparin. Transfusion of whole blood or fresh frozen plasma may also be required to replace lost volume if haemorrhaging has been severe; this may dilute, but will not neutralise, the effects of heparin. Explanation A. Vitamin K is a procoagulant, that is concerned with Warfarin and not heparin. B. Whole blood is for volume loss and cannot correct bleeding. C. Protamine is the correct drug 1 mg for 100 U of heparin. It is a strongly basic compund and is obtained from the sperm of certain fish. D. Ascorbic acid is vitamin C, and can be given for gum bleeding if it is due to scurvy. Comments Obviously, there are two problems in heparin overdose. 1. AnticoagualtionBleeding 2. Blood LossHypovolaemia dZX(xKddd ,(xKdd8 (xKdd;h(xKddd*h(xKdddh(xKdddh(xKddd 216. Granulocytopenia, gingival hyperplasia and facila hirsutism are all possible side effects of one of the following anticonvulsant drugs: A. Phenytoin. B. Valproate. C. Carbamazepine. D. Phenobarbitone. Answer: A (Phenytoin) Ref: Katzung, 7th edn, 391; KDT 5th edn, 372 & 4th edn, 385 Quality: Spotter First Clinical Status: Repeat QTDF: All books!! Discussion The adverse effects of phenytoin are: 1. Gum hyperplasia 2. Hirsutism, acne 3. Hypersensitivity reactionsrashes, DLE, lymphadenopathy, neutropenia which requires discontinuation of therapy 4. Megaloblastic anaemia due to decreased absorbtion and increased excretion of folic acid 5. Granulocytopenia and even pancytopenia 6. Osteomalacia 7. Hyperglycaemia due to inhibition of insulin release 8. Foetal hydantoin syndrome: a. Hypoplastic phalanges b. Cleft palate c. Hare lip d. Microcephaly Explanation A. Phenytoin causes all the features given above. B. Valproate causes fulminant hepatitis and during pregnancy neural tube defects in offspring. C. Carbamazepine produces dose related neurotoxicity and hepatitis, lupus like syndrome, rarely agranulocytosis and aplastic anaemia. D. Phenobarbitone causes rashes, megaloblastic anaemia and osteomalacia. Comments Side effects of the drugs are best read from the Table in Harrison. Tips Note the 5 H in the adverse effects Hyperplasia of gums Hirsutism Hypersensitivity reactions Hyperglycaemia Hydantoin syndrome 217. Cardiac or central nervous system toxicity may result when standard lidocaine doses are administered to patients with circulatory failure. This may be due to the following reason: A. Lidocaine concentration are initially higher in relatively well-perfused tissues such as brain and heart. B. Histamine receptors in brain and heart get suddenly activated in circulatory failure. C. There is a sudden out-burst of release of adrenaline, noradrenaline and dopamine in brain and heart. D. Lidocaine is converted into a toxic metabolite due to its longer stay in liver. Answer: A (Lidocaine concentration is initially higher in relatively well-perfused tissues such as brain and heart) Ref: Harrison 15th edn, 425 and Figure 70.1; Satoskar 17th edn, 384; Goodman Gillman 10th edn Quality: Reader, if you had read it Status: New QTDF: Harrison Discussion Lidocaine is a rapidly active drug. In circulatory failure, due to decreased hepatic flow, the metabolism of lidocaine is hampered and this leads to high levels in blood and obviously the high levels affect the well-perfused tissues. Explanation Lidocaine concentration are initially higher in relatively well-perfused tissues such as brain and heart. And this is the reason for cardiac or central nervous system toxicity when standard lignocaine is given to this patient. Comments Question for Anaesthetists. Tips A word about ester and amide local anaesthetics. If the name of the anaesthetic agent has two times the alphabet i, it is an amide, e.g. Prilocaine, Lignocaine, Dibucaine. If the name of the anaesthetic agent has the alphabet i only once, it is an ester, e.g. Cocaine, Tetracaine, Benzocaine. 218. Bostentan is a: A. Serotonin uptake inhibitor. B. Endothelin receptor antagonist. C. Leukotriene modifier. D. Calcium sensitiser. Answer: B (Endothelin receptor antagonist) Ref: CMDT 2002 Page 450; http://www.pharmacist.com/new_drug/tracleer.cfm Quality: Reader Read the latest books !! Status: New Question QTDF: CMDT, Journals Discussion It is endothelin receptor antagonist Generic name: Bosentan Manufacturer: Actelion Drug Class: Prostacyclin Dual endothelin receptor antagonist Indications: Treatment of pulmonary arterial hypertension. Dosage: Initiate treatment at an oral dosage of 62.5 mg twice daily for 4 weeks and then increase to a maintenance dosage of 125 mg twice daily. Evidence of liver damage present in 14% of patients in Bosentan: Randomised Trial of Endothelin Receptor Antagonist Therapy trial, but no evidence suggests agent can cause irreversible liver damage. It has been made available to patients at the University of Pittsburgh Medical Centre as part of a clinical trial. Bosentan works by blocking the action of a hormone called endothelin. Endothelin exists in higher levels in people with PH is a hormone that is harmful to the lung and pulmonary arteries. The damaged lung and pulmonary arteries create the blood flow resistance that results in hypertension. Bosentan was designed to offset endothelin, lowers the endothelin levels, reversing its effects, resulting in lower artery pressure. Tracleer blocks the action of endothelin, a substance made by the body. Endothelin narrows blood vessels and elevates blood pressure. Although endothelin is present in healthy people, high concentrations of the hormone have been found in the plasma and lungs of patients with PAH suggesting it is capable of causing the disease. Liver function tests are needed. Because of its potential to cause birth defects, Tracleer must not be prescribed to pregnant women. Female patients of childbearing potential must, therefore, take measures to prevent pregnancy, and monthly pregnancy testing will be required. Explanation A. Serotonin uptake inhibitors are Fluoxetine, Fluvoxamine, Paroxetine. B. Endothelin receptor antagonist. C. Leukotriene modifiers are Montelukast and Zafirlukast. D. Calcium sensitiser is Levosimendan. Comments Myocardial stunning refers to the phenomenon of transient myocardial dysfunction after brief periods of coronary ischaemia and reperfusion. During stunning, there is less myocardial fibre shortening and myocardial oxygen consumption is near normal, indicating a low efficiency of the contractile apparatus. Depressed responsiveness of the myofilaments to Ca ions is regarded as an important factor in the process of stunning. Levosimendan (Levo) increases the sensitivity of troponin C in a Ca-dependent way. 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No active management as heparin action disappears in few hours. 2. Protamine if there is still bleeding. ALL Medical and Pharmacological Books say this: Blood loss is managed by: 1. Whole blood transfusionTripathi as above The question asks management of bleeding... the answer is obviously Protamine. Tips Heparin is an enzyme activator, whereas most of the drugs we use are enzyme inhibitors. Another enzyme activator is P2AM. Forskalin activates adenylate cyclase, etc. 222. Bacitracin acts on: A. Cell wall B. Cell membrane. C. Nucleic acid. D. Ribosome. Answer: A (Cell wall) Ref: Katzung, 7th edn, 739; KDT 5th edn, 693 & 4th edn, 672 to 673 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this. Discussion Bacitracin acts by inhibiting cell wall synthesis at a step earlier than that inhibited by penicillins. It is a polypeptide and a topical agent. It is got from Bacillus subtilis. Explanation A. Bacitracin acts on the cell wall. B. Antifungals act on cell membrane. C. Drugs like ciprofloxacin act on nucleic acid. D. Drugs like tetracycline act on the ribosome. Comments The various drugs acting in the cell wall, however, act at different levels. Tips As always the question are from Anti group of drugs; Anti Epilepsy, Anticholinergics Antituberculous, Anti-leprosy, Antimalarial, Antifungal, Antibiotics, and Anti-histaminics. 223. All of the following drugs act on cell membrane, except: A. Nystatin. B. Griseofulvin. C. Amphotericin B. D. Polymixin B. Answer: B (Griseofulvin) Ref: KDT 5th edn, 693 & 4th edn, 672 to 673 & 774 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this. Discussion Cell wall synthesis inhibition Penicillins Cephalosporins Cycloserine Vancomycin Bacitracin Cell membrane leakage Poly peptides: Polymyxins, Poly peptides: Colistin Polyenes: Amphotericin B, Polyenes: Nystatin, Polyenes: Hamycin Protein synthesis inhibition Tetracyclines Chloramphenicol Macrolides-erythromycin Clindamycin mRNA misreading Aminoglycosides DNA gyrase inhibition Fluroquinolones DNA function inhibtion Metronidazole, Rifampicin DNA synthesis inhibition Acyclovir, Idoxuridine, Ziovudine Intermediary metabolism inhibition Sulphonamides, Trimethoprim Pyrimethamine Ethambutol PAS Explanation A. Nystatin [Katzung-786] produces micropores in the fungal cell membrane. B. Griseofulvin [Katzung-785] interferes with mitosis C. Amphotericin B [Katzung-780] produces micropores in the fungal cell membrane. D. Polymyxin B [Katzung-804] produces pseudopores in the bacterial cell membrane. Comments Mechanism of action of antibiotics is a favoured topic. Tips Read the classification in Page 672 to 673 KDT 4th Edition 224. The most effective drug against M. leprae is: A. Dapsone. B. Rifampicin. C. Clofazamine. D. Prothionamide. Answer: B (Rifampicin) Ref: Harrisons, 15th edn, 1039; KDT 5th edn, 711 & 4th edn, 766 Status: Repeat QTDF: KDT Discussion Established agents used to treat leprosy include: 1. dapsone (50 to 100 mg/d), 2. clofazimine (50 to 100 mg/d, 100 mg three times weekly, or 300 mg monthly), and 3. rifampin (600 mg daily or monthly). Of these drugs, only rifampin is bactericidal. The sulphones (folate antagonists), the foremost of which is dapsone, were the first antimicrobials found to be effective for the treatment of leprosy and are still the mainstay of therapy. With sulphone treatment, skin lesions resolve and numbers of viable bacilli in the skin are reduced. Although primarily bacteriostatic, dapsone monotherapy results in only a 10% resistance-related relapse rate; after 18 years of therapy and subsequent discontinuation, only another 10% of patients relapse, developing new, usually asymptomatic, shiny, histoid nodules. Dapsone is generally safe and inexpensive. Individuals with glucose-6-phosphate dehydrogenase deficiency who are treated with dapsone may develop severe haemolysis; those without this deficiency also have reduced red cell survival and a haemoglobin decrease averaging 1 g/dL. Dapsones usefulness is limited occasionally by allergic dermatitis and rarely by the sulphone syndrome (including high fever, anaemia, exfoliative dermatitis, and a mononucleosis-type blood picture). It must be remembered that rifampin induces microsomal enzymes, necessitating increased doses of medications such as glucocorticoids and oral birth control regimens. Clofazimine is often cosmetically unacceptable to light-skinned leprosy patients because it causes a red-black skin discolouration that accumulates, particularly in lesional areas, and makes the patients diagnosis obvious to members of the community. Other antimicrobial agents active against M. leprae in animal models and at the usual daily doses used in clinical trials include ethionamide/prothionamide; the aminoglycosides streptomycin, kanamycin, and amikacin (but not gentamicin or tobramycin); minocycline; clarithromycin; and several fluoroquinolones, particularly ofloxacin. Next to rifampin, minocycline, clarithromycin, and ofloxacin appear to be most bactericidal for M. leprae, but these drugs have not been used extensively in leprosy control programmes. Explanation A. Dapsone is the mainstay. B. Rifampicin is the most effective. C. Clofazamine is also used. D. Prothionamide, a congener of ethionamide that is not available in the United States, has pharmacologic properties similar to those of ethionamide and is widely used throughout the world. Comments Rifampicin is most effective as it is cidal, Dapsone is the mainstay. Tips While ethionamide (250 mg/d) has not been approved by the FDA for the treatment of leprosy, it is sometimes used in the United States in combination with rifampin (600 mg/d) to treat dapsone-resistant leprosy in patients who cannot accept the skin-depigmentation effect of clofazimine. Because resistance to ethionamide develops quickly when the drug is used alone, it must be used with other effective agents. 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'\P-kDlGáD*w-kDLD*w-k '\P-kDlGáD*w-kDLD*w-k00Pp0PP  tL0񄋋D_-kD'|x%A\Pb '\P-kDlGáD*w-kDLD*w-k  0pP,0PP @|//@!@ff.@.-[-g00%%(@(@m m  m m @6    @ @n           O   @        +@    @?@@=@  @ @@:cug may be incompletely absorbed. 2. The absorbed drug may undergo first pass metabolism in intestinal wall/liver or may be excreted in bile IM/SC Route may be associated with a low bioavailability and that is due to: a. Local binding. Bioavailability is determined by the area under the plasma concentration-time curve. Explanation A. It is the proportion (fraction) of unchanged drug that reaches the systemic circulation. B. Bioavailability of an orally administered drug can be calculated by comparing the area under curve (0- ) after oral and intravenous (IV) administration. C. Low oral bioavailability always and necessarily does not mean poor absorption. It could be also due to first pass metabolism. D. Bioavailability can be determined from plasma concentration or urinary excretion data. Comments A drug with low bioavailability will have a very high oral dose compared to its parenteral dose (e.g. Propanolol). Tips This is an area from which few problems may be asked. 213. The extent to which ionisation of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. Which of the following statements is not correct. A. pKa of a drug is the pH at which the drug is 50% ionised. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely ionised at acid pH and will be about 40% non-ionised in plasma. Answer: D (Phenobarbitone with a pKa of 7.2 is largely ionised at acid pH and will be about 40% non-ionised in plasma) Ref: KDT 5th edn, 12 Figure 2.3 & 4th edn, 2 Pages 11,12 Fig 2.3; Harper 25th edn, 23 Figures 3.6, 3.7 Quality: Thinker, needs basic concepts Status: New QTDF: KDT, Harper Discussion pKa of a substance is the pH at which it is 50% ionised. And small changes of pH near its pKa will not affect the ionisation of acidic as well as basic drugs. And, of course, the knowledge of pKa is needed in predicting the behaviour of various drugs in body fluids. Just because we know the pKa of Aspirin, we are able to understand why it is selectively concentrated in the gastric mucosa at concentration much higher than that of the gastric lumen. Because we know the pKa of Phenobarbitone, we are able to use forced alkaline diuresis for its excretion. Explanation A. pKa of a drug is the pH at which the drug is 50% ionised. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely unionised at acid pH and is more ionised in alkaline pH. Remember forced alkaline diuresis for phenobarbituric acid!!!!) Comments This question can be solved easily if one knows the basic concepts of acid, base and pH. Tips As already told, if one has strong correct concepts in acid-base and electrolyte balance, about 5% of questions can be attended with minimum fuss. This question carries a chance of being wrongly interpreted and considering answer D as correct. Be careful !!! and option D is a WRONG statement and the correct answer Phenobarbitone is Phenobarbituic acid and is not a basic drug !!! Considering option D as a correct statement and hence going for another option as the answer. 214. Presence of food might be expected to interfere with drug absorption by slowing gastric emptying, or by altering the degree of ionisation of the drug in the stomach. Which of the following statements is not correct example? A. Absorption of digoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food enhances the absorption of hydrochlorthiazide. D. Anitimalarial drug halofantriene is more extensively absorbed if taken with food. Answer: C (Presence of food enhances the absorption of hydrochlorthiazide) Ref: KDT 5th edn, 372 (Phenytoin), 748 (Halofantriene) and 4th edn, 492(digoxin), 384(Phenytoin), 565(Thiazides), Halofantriene Park, Katsung, Harrison 15th edn, Table 414-4; Goodman Gilman 9th edn, 957; CMDT 2003,1441 Quality: Thinker Status: New QTDF: ?? Discussion Presence of food generally dilutes the drug and retards absorption. Certain drugs form complexes with certain constituents of the food. For example, tetracycline complexes with calcium and more over food delays gastric emptying. Thus, most drugs are better absorbed if taken in empty stomach. But few drugs which are irritant are better given with food. Explanation A. Absorption of digoxin as well as digitoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food has no effect on the absorption of hydrochlorthiaside. D. Anitimalarial drug halofantriene is more extensively absorbed if taken with fatty food (Katsung). Comments A question for which one needs knowledge of Pharmacokinetics (often ignored). Tips Make a note of drugs that are increased with food (other than Halofantriene). 215. In post-operative intensive care unit, five patients developed post-operative wound infection on the same day. The best method to prevent cross infection occurring in other patients in the same ward is to: A. Give antibiotics to all other patients in the ward. B. Fumigate the ward. C. Disinfect the ward with sodium hypochlorite. D. Practice proper hand washing. Answer: D (Practice proper hand washing) Ref: Katzung 7th edn, 805; ,@ l hhhhh,@ l ,@ l \hXQ,@ l ,@ l ,@ l +,@ l ,@ l ,@ l ,@ l ,@ l hOhhW,@ l ,@ l ]X~X|,@ l ,@ l 6,@ l ,@ l hrX{,@ l <,@ l ',@ l ,@ l Xca: CXh$,@ l hhhhh ,@ l XTX ,@ l 8,@ l ,@ l >,@ l 4hXXXX,@ l ,@ l ,@ l ,@ l ",@ l ,@ l ,@ l 3,@ l h,@ l ,@ l X&XXX ,@ l H,@ l ,@ l z,@ l ,@ l ,@ l 9,@ l ,@ l ,@ l fefffeffffffffffffffffffffffffffffffffffffffffffffffffffffffThe break up is: General Pharmac 4 Cardiology 2 Neurology 2 Haematology 2 Antibiotics 3 Since the fifth edition of KDT has been released just now, it is felt that few will be having the old fourth edition as well. So both books are given for reference. 212. All of the following statements regarding bioavailability of a drug are true, except: A. It is the proportion (fraction) of unchanged drug that reaches the systemic circulation. B. Bioavailability of an orally administered drug can be calculated by comparing the area under curve (0- ) after oral and intravenous (IV) administration. C. Low oral bioavailability always and necessarily mean poor absorption. D. Bioavailability can be determined from plasma concentration or urinary excretion data. Answer: C (Low oral bioavailability always and necessarily mean poor absorption) Ref: Katzung, 7th edn, 40; KDT 5th edn, 15 & 4th edn, 15 Figure 2.4 Quality: Reader Status: New QTDF: KDT Discussion Bioavailability of a drug is defined as the fraction of unchanged drug reaching the systemic circulation following administration by any route. Following intravenous route the bioavailablilty is 100%. Oral route is associated with low bioavailability due to the following reasons: 1. The drug may be incompletely absorbed. 2. The absorbed drug may undergo first pass metabolism in intestinal wall/liver or may be excreted in bile IM/SC Route may be associated with a low bioavailability and that is due to: a. Local binding. Bioavailability is determined by the area under the plasma concentration-time curve. Explanation A. It is the proportion (fraction) of unchanged drug that reaches the systemic circulation. B. Bioavailability of an orally administered drug can be calculated by comparing the area under curve (0- ) after oral and intravenous (IV) administration. C. Low oral bioavailability always and necessarily does not mean poor absorption. It could be also due to first pass metabolism. D. Bioavailability can be determined from plasma concentration or urinary excretion data. Comments A drug with low bioavailability will have a very high oral dose compared to its parenteral dose (e.g. Propanolol). Tips This is an area from which few problems may be asked. 213.The extent to which ionisation of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. Which of the following statements is not correct? A. pKa of a drug is the pH at which the drug is 50% ionised. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely ionised at acid pH and will be about 40% non-ionised in plasma. Answer: D (Phenobarbitone with a pKa of 7.2 is largely ionised at acid pH and will be about 40% non-ionised in plasma) Ref: KDT 5th edn, 12 Figure 2.3 & 4th edn, 2 Pages 11,12 Fig 2.3; Harper 25th edn, 23 Figures 3.6, 3.7 Quality: Thinker, needs basic concepts Status: New QTDF: KDT, Harper Discussion pKa of a substance is the pH at which it is 50% ionised. And small changes of pH near its pKa will not affect the ionisation of acidic as well as basic drugs. And, of course, the knowledge of pKa is needed in predicting the behaviour of various drugs in body fluids. Just because we know the pKa of Aspirin, we are able to understand why it is selectively concentrated in the gastric mucosa at concentration much higher than that of the gastric lumen. Because we know the pKa of Phenobarbitone, we are able to use forced alkaline diuresis for its excretion. Explanation A. pKa of a drug is the pH at which the drug is 50% ionised. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely unionised at acid pH and is more ionised in alkaline pH. Remember forced alkaline diuresis for phenobarbituric acid!!!) Comments This question can be solved easily if one knows the basic concepts of acid, base and pH. Tips As already told, if one has strong correct concepts in acid-base and electrolyte balance, about 5% of questions can be attended with minimum fuss. This question carries a chance of being wrongly interpreted. Be careful !!! And option D is a WRONG statement and the correct answer. Phenobarbitone is Phenobarbituric acid and is not a basic drug !!! Considering option D as a correct statement and hence going for another option as the answer. 214. Presence of food might be expected to interfere with drug absorption by slowing gastric emptying, or by altering the degree of ionisation of the drug in the stomach. Which of the following statements is not correct example? A. Absorption of digoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food enhances the absorption of hydrochlorthiazide. D. Anitimalarial drug halofantriene is more extensively absorbed if taken with food. Answer: C (Presence of food enhances the absorption of hydrochlorthiazide) Ref: KDT 5th edn, 372 (Phenytoin), 748 (Halofantriene) and 4th edn, 492(digoxin), 384(Phenytoin), 565(Thiazides), Halofantriene Park, Katsung, Harrison 15th edn, Table 414-4; Goodman Gilman 9th edn, 957; CMDT 2003,1441 Quality: Thinker Status: New QTDF: ?? Discussion Presence of food generally dilutes the drug and retards absorption. Certain drugs form complexes with certain constituents of the food. For example, tetracycline complexes with calcium and moreover food delays gastric emptying. Thus, most drugs are better absorbed if taken in empty stomach. But few drugs which are irritant are better given with food. Explanation A. Absorption of digoxin as well as digitoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food has no effect on the absorption of hydrochlorthiaside. D. Anitimalarial drug halofantriene is more extensively absorbed if taken with fatty food (Katsung). Comments A question for which one needs knowledge of Pharmacokinetics (often ignored). Tips Make a note of drugs that are increased with food (other than Halofantriene). 215. In post-operative intensive care unit, five patients developed post-operative wound infection on the same day. The best method to prevent cross infection occurring in other patients in the same ward is to: A. Give antibiotics to all other patients in the ward. B. Fumigate the ward. C. Disinfect the ward with sodium hypochlorite. D. Practice proper hand washing. Answer: D (Practice proper hand washing) Ref: Katzung 7th edn, 805; 216. Granulocytopenia, gingival hyperplasia and facila hirsutism are all possible side effects of one of the following anticonvulsant drugs: A. Phenytoin. B. Valproate. C. Carbamazepine. D. Phenobarbitone. Answer: A (Phenytoin) Ref: Katzung, 7th edn, 391; KDT 5th edn, 372 & 4th edn, 385 Quality: Spotter First Clinical Status: Repeat QTDF: All books!! Discussion The adverse effects of phenytoin are: 1. Gum hyperplasia 2. Hirsutism, acne 3. Hypersensitivity reactionsrashes, DLE, lymphadenopathy, neutropenia which requires discontinuation of therapy 4. Megaloblastic anaemia due to decreased absorbtion and increased excretion of folic acid 5. Granulocytopenia and even pancytopenia 6. Osteomalacia 7. Hyperglycaemia due to inhibition of insulin release 8. Foetal hydantoin syndrome: a. Hypoplastic phalanges b. Cleft palate c. Hare lip d. Microcephaly Explanation A. Phenytoin causes all the features given above. B. Valproate causes fulminant hepatitis and during pregnancy neural tube defects in offspring. C. Carbamazepine produces dose related neurotoxicity and hepatitis, lupus like syndrome, rarely agranulocytosis and aplastic anaemia. D. Phenobarbitone causes rashes, megaloblastic anaemia and osteomalacia. Comments Side effects of the drugs are best read from the Table in Harrison. Tips Note the 5 H in the adverse effects Hyperplasia of gums Hirsutism Hypersensitivity reactions Hyperglycaemia Hydantoin syndrome 217. Cardiac or central nervous system toxicity may result when standard lidocaine doses are administered to patients with circulatory failure. This may be due to the following reason: A. Lidocaine concentration are initially higher in relatively well-perfused tissues such as brain and heart. B. Histamine receptors in brain and heart get suddenly activated in circulatory failure. C. There is a sudden out-burst of release of adrenaline, noradrenaline and dopamine in brain and heart. D. Lidocaine is converted into a toxic metabolite due to its longer stay in liver. Answer: A (Lidocaine concentration is initially higher in relatively well-perfused tissues such as brain and heart) Ref: Harrison 15th edn, 425 and Figure 70.1; Satoskar 17th edn, 384; Goodman Gillman 10th edn Quality: Reader, if you had read it Status: New QTDF: Harrison Discussion Lidocaine is a rapidly active drug. In circulatory failure, due to decreased hepatic flow, the metabolism of lidocaine is hampered and this leads to high levels in blood and obviously the high levels affect the well-perfused tissues. Explanation Lidocaine concentration are initially higher in relatively well-perfused tissues such as brain and heart. And this is the reason for cardiac or central nervous system toxicity when standard lignocaine is given to this patients. Comments Question for Anaesthetists. Tips A word about ester and amide local anaesthetics. If the name of the anaesthetic agent has two times the alphabet i, it is an amide, e.g. Prilocaine, Lignocaine, Dibucaine. If the name of the anaesthetic agent has the alphabet i only once, it is an ester, e.g. Cocaine, Tetracaine, Benzocaine. 218. Bostentan is a: A. Serotonin uptake inhibitor. B. Endothelin receptor antagonist. C. Leukotriene modifier. D. Calcium sensitiser. Answer: B (Endothelin receptor antagonist) Ref: CMDT 2002 Page 450; http://www.pharmacist.com/new_drug/tracleer.cfm Quality: Reader Read the latest books !! Status: New Question QTDF: CMDT, Journals Discussion It is endothelin receptor antagonist Generic name: Bosentan Manufacturer: Actelion Drug Class: Prostacyclin Dual endothelin receptor antagonist Indications: Treatment of pulmonary arterial hypertension. Dosage: Initiate treatment at an oral dosage of 62.5 mg twice daily for 4 weeks and then increase to a maintenance dosage of 125 mg twice daily. Evidence of liver damage present in 14% of patients in Bosentan: Randomised Trial of Endothelin Receptor Antagonist Therapy trial, but no evidence suggests agent can cause irreversible liver damage. It has been made available to patients at the University of Pittsburgh Medical Centre as part of a clinical trial. Bosentan works by blocking the action of a hormone called endothelin. Endothelin exists in higher levels in people with PH is a hormone that is harmful to the lung and pulmonary arteries. The damaged lung and pulmonary arteries create the blood flow resistance that results in hypertension. Bosentan was designed to offset endothelin, lowers the endothelin levels, reversing its effects, resulting in lower artery pressure. Tracleer blocks the action of endothelin, a substance made by the body. Endothelin narrows blood vessels and elevates blood pressure. Although endothelin is present in healthy people, high concentrations of the hormone have been found in the plasma and lungs of patients with PAH suggesting it is capable of causing the disease. Liver function tests are needed. Because of its potential to cause birth defects, Tracleer must not be prescribed to pregnant women. Female patients of childbearing potential must, therefore, take measures to prevent pregnancy, and monthly pregnancy testing will be required. Explanation A. Serotonin uptake inhibitors are Fluoxetine, Fluvoxamine, Paroxetine. B. Endothelin receptor antagonist. C. Leukotriene modifiers are Montelukast and Zafirlukast. D. Calcium sensitiser is Levosimendan. Comments Myocardial stunning refers to the phenomenon of transient myocardial dysfunction after brief periods of coronary ischaemia and reperfusion. During stunning, there is less myocardial fibre shortening and myocardial oxygen consumption is near normal, indicating a low efficiency of the contractile apparatus. Depressed responsiveness of the myofilaments to Ca ions is regarded as an important factor in the process of stunning. Levosimendan (Levo) increases the sensitivity of troponin C in a Ca-dependent way. 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Ref: Nema 4th Edition page 118 Quality: Spotter Status: New QTDF: Nema Discussion International trachoma Initiative sponsors a programme called SAFE to control Trachoma Surgery, Antibiotics, Facewash & Environmental change Explanation Self Explanatory Comments Be aware of the latest facts Tips Trachoma is an important topic and question can come from Staging, Complication, and Management Question. 265. The commonest cause of low vision in India is: 1.Uncorrected refractive errors. 2.Cataract. 3.Glaucoma. 4.Squint. Answer: 1.Uncorrected refractive errors. Ref: Pradeep Sharma 1st Edition Page 338 to 340 (causes of Low Vision) Nema 4th Edition Page 399 (Causes for Blindness) Park 16th Edition Page 301 (Causes for Blindness) Quality: Spotter Status: Repeat (with change) QTDF: ?? Discussion Causes of Low Vision are Refractive Errors 14.2 % Cataract 7.68 % Trachoma 4.02 % Vitamin A Deficiency 1.32 % Central Corneal Opacity 0.73 % Glaucoma 0.07 % Causes of Blindness Cataract 80.10 % Refractive Errors 7.35 % Aphakia 4.67 % Glaucoma 1.70 % Corneal Opacities 1.52 % Trachoma 0.35 % Others 4.25 % Explanation Self Explanatory Comments Refractive Error Causes low vision on 100 % of cases Tips This is an often repeated question. Make sure you correctly interpret what is asked in the question. Question. 266. Elemental iron and folic acid contest of iron & folic acid adult tablets supplied under the National Programme for Anaemia Prophylaxis are: A. 60mg of elemental iron and 250 micrograms of folic acid. B. 100 mg of elemental iron and 500 micrograms of folic acid. C. 120 mg of elemental iron and 750 micrograms of folic acid. D. 200 mg of elemental iron and 1000 micrograms of folic acid. Answer: B. 100 mg of elemental iron and 500 micrograms of folic acid. Ref: Park 17th Edition Page 363, 439 Park 16th Edition Page 356 gives answer as 60 mg of Iron and 500 mcg of Folic Acid Quality: Spotter Status: Repeat Question with new choices QTDF: Park, 17th Edition Discussion As Anaemia is the main culprit behind Prematrure births, Postpoartum haemorrhage, Puerperal Sepsis, and thromboembolic phenomena in the mother, the government of India has initiated a programme in which 60 mg of Elemental Iron and 500 mcg of Folic Acid are given through Antenatal Clinics, PHCs and their subcentres . Please note that we have to give 500 mcg of Folic Acid Explanation A. 60mg of elemental iron and 250 micrograms of folic acid was never given. Instead 60 mg of Iron and 500 mcg of Folic Acid was once given. B. 100 mg of elemental iron and 500 micrograms of folic acid is given now. C. 120 mg of elemental iron and 750 micrograms of folic acid is not the correct dose. D. 200 mg of elemental iron and 1000 micrograms of folic acid is not the correct dose. Comments A question from Park 17th Edition. (In older editions it is given as 60 mg of Iron but nevertheless the dose of Folic Acid is 500 mcg and so you have to choose only choice 2 even if you go by the book. Note that oral Iron is slightly increased doses is not toxic where as Folic Acid is essential) Tips Questions on Iron Metabolism and Anaemia Question can pop up from Any subject from Physiology to OG and are often repeated and can be easily answered Question. 267. Elemental iron and folic acid contents of pediatric iron-folic acid tablets supplied under Rural child Health (RCH) Program are: A. 20 mg iron & 100 micrograms folic acid. B. 40 mg iron & 100 micrograms folic acid. C. 40 mg iron & 50 micrograms folic acid. D. 60 mg iron & 100 micrograms folic acid. Answer: A. 20 mg iron & 100 micrograms folic acid. Ref: Park 16th Edition Page 432 Park 17th Edition Page 439 Quality: Spotter Status: Repeat QTDF: Park Discussion In children (1-12 years) daily supplementation based on requirement of iron and folic acid is done to prevent mild and moderate cases of anemia. Each pediatric tablet contains 20 mg of elemental iron (60 mg of ferrous sulphate) and 100mcg (0.1 mg) of folic acid. Explanation Self Explanatory Comments A question that is being repeated for a long long time Tips Nutrition is an extremely important topic, both from SPM and Paediatric Point of View Question. 268. The Protein Efficiency Ratio (PER) is defined as: A. The gain in weight of young animals per unit weight of protein-consumed. B. The product of digestibility coefficient and biological value. C. The percentage of protein absorbed into the blood. D. The percentage of nitrogen absorbed from the protein absorbed from the diet. Answer: A. The gain in weight of young animals per unit weight of protein-consumed. Ref: Park 17th Edition Page 432 Textbook of Medical Biochemistry 4th Edition Chaterjee and ShindePage 702 Quality: Reader Status: New QTDF: Park Discussion Protein Energy Ratio is defined as the Ration of the weight increased in grams to the gms of proteins consumed u Protein efficiency ratio = Weight increase in gms Gms of protein consumed Biological value is defined as the percentage of absorbed nitrogen that is retained in the body u Biological value (B.V.) = Nitrogen retained X 100 Nitrogen absorbed Net protein utlilization (NPU) is defined as the percentage of nitrogen in the food, that is retained by the body u NPU = Nitrogen retained x 100 Nitrogen present in the food u NPU = Digestibility coefficient X Biological Value (B.V.) 100 Explanation A. The gain in weight of young animals per unit weight of protein-consumed is Protein Efficiency Ratio. B. The product of digestibility coefficient and biological value is Net Protein Utilisation x 100. C. The percentage of protein absorbed into the blood is Biological Value. D. The percentage of nitrogen absorbed from the protein absorbed from the diet is Net Protein Utilisation. Comments Tips Question. 269. Most important epidemiological tool used for assessing disability in children is: 1.Activities of Daily living (ADL) scale. 2.Wings Handicaps, Behavior and Skills (HBS) Schedule. 3.Binet and Simon IQ tests. 4.Physical Quality of Life Index (PQLI) Answer: 2.Wings Handicaps, Behavior and Skills (HBS) Schedule. Ref: Park 16th Edition Page 462 Park 17th Edition Page 469 Quality: Reader - You have to read the nook and corner of Park Status: New QTDF: Park (Yes !!! It is given in Park) Discussion There have been many attempts to measure or record in standardized forms, the aspects of behaviour, psychological function and social performance. One of the most important is Wings comprehensive Handicaps Behaviour and Skills (HBS) schedule which has been used in epidemiological studies to access the total child population In the 1970s, for purposes of their research, Wing and Gould (1978) designed the first interview schedule that was intended to elicit from informants, in systematic fashion, all the details concerning history and present clinical pictures needed to make a diagnosis of typical autism. This was called the Handicaps Behaviour and Skills (HBS) schedule. As a result of using this schedule in research, Wing and Gould (1979) came to realise that there was a whole spectrum of disorders that overlap with typical autism. These disorders all have in common a triad of impairments of social interaction, communication and imagination, and a narrow, repetitive pattern of activities. Explanation 1.Activities of Daily living (ADL) scale. ADL : Survey Based on 6 criteria u Bathing (sponge bath, tub bath, or shower) Receives either no assistance or assistance in bathing only one part of body u Dressing - Gets clothes and dresses without any assistance except for tying shoes. u Toileting - Goes to toilet room, uses toilet, arranges clothes, and returns without any assistance (may use cane or walker for support and may use bedpan/urinal at night u Transferring - Moves in and out of bed and chair without assistance (may use can or walker). u Continence - Controls bowel and bladder completely by self (without occasional accidents). u Feeding - Feeds self without assistance (except for help with cutting meat or buttering bread). TOTAL ADL SCORE: (Number of yes answers, out of possible 6.) Each criteria is graded on level of dependence u Performs independently u Performs with assistance u Unable to perform (assigned 1 point each) Interpretation u Level of ADL Dependence graded via score u Independent in ADLs suggested by score of 0 to 1 u Dependence in ADLs increases as score approaches 6 ADL used mainly in Geriatrics, especially Alzheimers disease 2.Wings Handicaps, Behavior and Skills (HBS) Schedule is the Most important epidemiological tool used for assessing disability in children 3.Binet and Simon IQ tests are used for testing IQ. 4.Physical Quality of Life Index (PQLI) consists of 3 indicators Infant Mortality rate Life expectancy at age one Literacy Comments Straight from Park Tips Of late more questions are asked from Park from hitherto unexplored areas Question. 270. Scope of family planning services include all of the following except: 1.Screening for cervical cancer. 2.Providing services for unmarried mothers. 3.Screening for HIV infection. 4.Providing adoption services. Answer 3.Screening for HIV infection. Ref: Park 17th Edition Page 335 & 16th Edition Page 329 Quality: Reader Status: Repeat QTDF: Park Discussion The scope of family planning services includes - 1. Proper spacing & limitation of births 2. Advice on sterility 3. Education for parenthood 4. Sex education 5. Screening for pathological conditions related to reproductive system e.g. cervical cancer 6. Genetic counseling 7. Premarital consultation & examination 8. Pregnancy test 9. Marriage counseling 10. Preparation of couples for arrival of their 1st child 11. Providing services for unmarried mother 12. Teaching home economics and nutrition 13. Providing adoption services Explanation 1.Screening for cervical cancer is done. 2.Providing services for unmarried mothers is done. 3.Screening for HIV infection is not done. 4.Providing adoption services is done. Comments Straight out of Park Tips Prepare a Mnemonic yourself Question. 271. Elements of primary health care include all of the following except: A. Adequate supply of safe water and basic sanitation. B. Providing essential drugs. C. Sound referral system. D. Health Education. Answer: C. Sound referral system. Ref: Park 16th Edition Page 632 Park 17th Edition Page 650 Quality: Reader Status: New QTDF: Park Discussion Elements of Primary Health Care Although specific services provided will vary ion different countries and communities, the Alma - Ata Declaration has outlined 8 essential components fo Primary Health Care. 1. Education concerning prevailing health problems and the methods of preventing and controlling them 2. Promotion of food supply and proper nutrition 3. An adequate supply of safe water and basic sanitation. 4. Maternal and child health care, including family planning 5. Immunization against Major Infectious diseases 6. Prevention and control of locally endemic diseases 7. Appropriate treatment of common diseases and Injuries 8. Provision of Essential Drugs Explanation A. Adequate supply of safe water and basic sanitation is an element of primary care. B. Providing essential drugs is an element of primary care. C. Sound referral system is not an element of primary care. D. Health Education is an element of primary care. Comments A question straight from Park Tips Use the Mnemonic ELIMENTS Education Locally Endemic Diseases Immunisation Maternal and Child health Care Essential Drugs Nutrition Treatment of Common Diseases Safe Water SURGERY 29 Questions Principles of Surgery (Schwartz) 3 Ulcers (Short Cases Das) 2 Swelling (Short Cases Das) 1 Arteries (Short Cases Das) 3 Veins (Short Cases Das) 1 Thyroid (Pathology and Medicine) 3 GIT (Path, Medicine and Paed) 5 Liver (Path, Medicine and Paed) 2 Urology (Schwartz, Sabiston, OTS) 9 Of the 29 Questions Bailey was not required for any of the questions. Short Cases in Surgery by Das emerged as a surprise Question Bank. This is a small book and most of the topics that are dealt there are dealt in detail. Though Questions are not being directly asked from Bailey now a days, With Short cases Das and Bailey you can attempt most of the questions if your knowledge in Path and Medicine are good. Question. 272. One unit of fresh blood raises the HB% concentration by: A. 0.1gm% B. 1 gm% C. 2 gm% D. 2.2 gm% Answer: B. 1gm% Ref: Washingtons Manual of Surgery Also found in PARAS - PARAS 4th Edition : Page 30 SARP - SARP 6th Edition : Page 129 Sure Sucess in PG Entrance 1st Edition : Page 79 Quality: Spotter Status: New QTDF: Sabiston Discussion In India, l unit of blood = 350 ml (301 ml of blood + 49 ml of anticoagulant) while in western countries one unit contains 450 ml (out of which 63 ml is anticoagulant). One unit of blood raises the Hb by 0.8g% in India while in western countries by 1g%. Explanation Self-Explanatory Comments Given in Sabiston and other Surgery books Tips There is another formula for calculating Iron requirement in Anaemia. Please be prepared with that also Question. 273. Early stage of trauma is characterized by: A. Catabolism B. Anabolism C. Glycogenesis. D. Gluconeogenesis. Answer: A. Catabolism Ref: Harper Bailey and Love 23rd Edition Page 65 Sabiston Chapter 19 Schwartzes 17th Edition Page 233, Page 80 Quality: Spotter Status: New QTDF: Schwartz Discussion In the early stage it is the Catabolic processes like Gycogenolysis which happen Gluconeogenesis starts only after Glycogenolysis which itself is Catabolism Explanation A. Catabolism (Glycogenolysis) starts first B. Anabolism occurs when the body is in a well-fed state C. Glycogenesis is Anabolism. D. Gluconeogenesis occurs after Glycogenolysis. Comments Adequate nutrition is a daily concern in any postoperative patient; in the context of ARF it assumes even greater importance. Acute uremia is a catabolic condition. The postoperative or trauma patient who cannot eat is also catabolic. Tissue catabolism in these patients releases potassium, acids, water, phosphorus, and nitrogenous products into the ECF. Tips Beware of the word early Question. 274. A 64-Year-old hypertensive obese female was undergoing surgery for fracture femur under general anaesthesia. Intra operatively her end-tidal carbon-dioxide decreased to 20 from 40mm of Hg. followed by hypotension and oxygen saturation of 85%. What could be the most probable cause? 1.Fat embolism. 2.Hypovolemia. 3.Bronchospasm. 4.Myocradial infarction. Answer: 1.Fat embolism. Ref: Sabiston Chapter 11 Anaesthesia Oxford Text book of Surgery Chapter 5.1 Respiratory Problems Quality: Reader Status: Repeat QTDF: Sabiston Discussion Capnometry provides measurement of end-tidal CO2 and display of exhaled CO2 waveforms (capnography). The most commonly used capnometers continuously withdraw a small (150 ml/min) sample of gas distally to the Y-piece connector of the breathing circuit. Modifications to face-masks, nasal airways, and nasal cannulas have been designed to facilitate capnography in the awake patient, enabling the capnograph to serve as an apnoea monitor. The CO2 tension recorded at end-expiration (end-tidal CO2) reflects the Pco2; in the alveolar gas, which in normal circumstances is slightly lower (2-4 mmHg) than the arterial Pco2. A higher arterial to end-tidal Pco2; gradient reflects an increase in VD/VT A sudden fall in the end-tidal Pco2 may be due to an acute decrease in cardiac output, to pulmonary embolism or to air embolism. Useful applications of capnometry in the operating room include: detection of accidental oesophageal intubation by absence of a CO2 waveform, inadequate ventilation, disconnection of a component of the breathing system, CO2 rebreathing from an exhausted CO2 absorber or a malfunctioning valve. Capnometry may allow early detection of air embolism during sitting craniotomy, spinal fusion or hip surgery, by a sudden decrease of end-tidal CO2 secondary to a decreased cardiac output or to sampling of gas lower in CO2, which diffuses into the alveoli from the pulmonary capillaries. Capnography may be useful in the intensive care unit in mechanically ventilated patients, where the adequacy of ventilation in response to physiological or mechanical changes may be assessed immediately. End-tidal carbon dioxide measurement (capnography) gives valuable information on the effectiveness of ventilation as well as certain disease states, such as chronic obstructive pulmonary disease and pulmonary embolism. It is very important and sensitive tool for monitoring in anaesthesia. ETCO2 decreases suddenly in pulmonary embolism by fat, air or thrombus. Explanation 1.Fat embolism is the correct answer as the End Tidal CO2 and Oxygen saturation decreases. 2.Hypovolemia will cause hypotension, but End Tidal CO2 and Oxygen saturation will not decrease. 3.Bronchospasm will not cause Hypotension. 4.Myocradial infarction will cause hypotension as well as Hypoxia, but End Tidal CO2 is rarely affected Comments Remember that the Surgery is for Fracture Femur Tips Capnographs monitor spontaneously breathing patients ventilatory status, warn of airway leaks and ventilator circuit disconnections, and ensure proper endotracheal tube placement. Question. 275. Bedsore is an example of: 1.Tropical ulcer. 2.Trophic ulcer. 3.Venous ulcer. 4.Post thrombotic ulcer. Answer: 2.Trophic ulcer. Ref: Bailey & Love,23rd Edition,Page 158 & 220 Short Cases in Surgery by S.Das 2nd Edition Page 46 Quality: Spotter - Final MBBS Status: Unexpectedly new !! QTDF: Short Case Das Discussion Trophic ulcer, perforating ulcer of foot, trophic gangrene is a Ulcer resulting from cutaneous sensory denervation and is a round, deep, trophic ulcer, following disease or injury, in any part of its course from the centre to the periphery of the nerve supplying the part. It is also called as Neurogenic Ulcer, Neuropathic Ulcer or Penetating Ulcer. It occurs in heel and ball of the foot in Ambulatory patients and Buttocks and back in Non Ambulatory patients. Explanation 1.Tropical ulcer or tropical sore is the lesion occurring in cutaneous leishmaniasis, tropical phagedenic ulceration caused by a variety of microorganisms, including mycobacteria; and is common in northern Nigeria. B. Bed sore comes under the category of Trophic ulcer. 3.Venous ulcer is caused by the stagnation due to varicose veins. 4.Post thrombotic ulcer is venous ulcer. Comments A simple, unexpected question Tips Bed Sore is a chronic ulcer that appears in pressure areas in debilitated patients confined to bed or otherwise immobilised, due to a circulatory defect from the enhanced tissue pressure in high-contact areas, often occurring over a bony prominence (for example sacral decubitus). Question. 276. Marjolins ulcer is a: 1.Malignant ulcer found on the scar of burn. 2.Malignant ulcer found on infected foot. 3.Tropic ulcer. 4.Melencys gangrene. Answer: 1.Malignant ulcer found on the scar of burn. Ref: Bailey & Love 23rdEdition Page 180 Short Cases in Surgery by S.Das 2nd Edition Page 28 Schwartz 7th Edition Page 257 Quality: Spotter Final MBBS Status: Repeat QTDF: Bailey Discussion Marjolins Ulcer is a Squamous cell Carcinoma arising from a scar or ulcer. The scar that commonly is transformed to a Marjolins Ulcer is the Scar of Burns and the ulcer is the chronic Venous Ulcer. The previous inflammation destroys the cutaneous nerves and lymphatics and to a certain extent the blood vessels. The carcinoma is therefore slow growing, painless and rarely there is metastasis. Explanation 1.Malignant ulcer found on the scar of burn is the classical Marjolins ulcer. 2.Malignant ulcer is also found on infected foot and is usually squamous cell carcinoma. 3.Tropic ulcer or tropical sore is the lesion occurring in cutaneous leishmaniasis, tropical phagedenic ulceration caused by a variety of microorganisms, including mycobacteria; and is common in northern Nigeria. 4.Melencys gangrene or Meleneys ulcer or progressive bacterial synergistic gangrene is an Undermining ulcer of the skin and subcutaneous tissues, usually following an operation, caused by a synergistic interaction between microaerophilic nonhemolytic streptococci and aerobic haemolytic staphylococci.. Comments This a reflex question for any one who has attended his ward posting regularly Tips Questions like these being asked in All India make us suggest you to read (at least the important topics in) the Clinical Das once before going to the exam Question. 277. The best treatment for cystic hygroma is: 1.Surgical excision. 2.Radiotherapy. 3.Sclerotherapy. 4.Chemotherapy. Answer: 1.Surgical excision. Ref: Bailey and Love 23rd Edition Page 201 Surgical Short Cases by Das 2nd Edition Chapter 8 Pages 137-139 Schwartz 7th Edition Page 1719 Quality: Spotter Final MBBS Status: Repeat QTDF: Bailey Discussion Excision is the treatment of choice for Cystic Hygroma Explanation Self-Explanatory Comments Even though Sclerotherapy is not advisable, few books say that sclerotherapy with water is done in the initial stages. But when Surgical Excision is given as one of the choices, you need not worry for anything Tips Refer Bailey and Surgical Short Cases by Das Question. 278. If a patient with Raynauds disease immersed his hand in cold water, the hand will 1.Become red. 2.Remain Unchanged. 3.Turn white. 4.Become blue. Answer: 3.Turn white. Ref: Bailey & Love,23rd Edition Page 232 Surgical Short Cases by Das 2nd Edition Page 211 -212 Quality: Reader Final MBBS Status: Repeat QTDF: Das Discussion Finger tip recovery time after digital ice water exposure: When exposed in Cold Water the tip becomes pale (white). The time taken for the fingers to regain the time is an index of Severity of the disease. Normally it is 5 to 10 minutes where as in the Raynauds Phenomenon, it remains pale for 20 minutes and then only regains the normal colour Explanation Self-Explanatory Comments However, all the colours given in the question occur in the fingers in the classical disease in various stages. Refer Das for details Tips Due to space constraints, the details are not given. However they can be best studied in Surgical Short Cases by Das Question. 279. Sympathectomy is indicated in all the following conditions except: A. Ischaemic ulcers. B. Intermittent claudication. C. Anhidrosis. D. Acrocyanosis. Answer: C. Anhidrosis. Ref: Bailey and Love 23rd Edition Page 207 Oxford Textbook of Surgery Page 370 Quality: Reader Status: Repeat Topic QTDF: Oxford Text book of Surgery Discussion Sympathetic denervation has been used in the treatment of limb, cardiac, and abdominal visceral pain. Open sympathectomy has largely been replaced by the use of oral or intravenous sympatholytic drugs, percutaneous radiofrequency lesions, and chemical procedures. The most common indications are those of causalgia, Sudecks atrophy, and ischaemic pain in the limbs due to peripheral vascular disease. Cardiac sympathectomy in the treatment of angina has largely been superseded by improved medication and coronary artery bypass grafts, although percutaneous radiofrequency cardiac sympathectomy may still have a place in the treatment of medically intractable pain. Malignant pain affecting the pancreas, liver, gallbladder, and stomach together with painful chronic relapsing pancreatitis has been treated by chemical sympathectomy of the caeliac plexus and splanchnic nerves using an injection of 50 per cent alcohol or phenol. Ischaemic limb pain may be helped by lumbar sympathectomy when surgery is inappropriate. Sympathectomy increases skin blood flow, and rest pain can be relieved in the majority of patients. The results are equivalent to surgical sympathectomy, but with lower morbidity and mortality. One of the enigmas is that the pain relief appears to last longer than the measurable haemodynamic effects of the procedure. Intermittent claudication is not helped reliably by sympathectomy, and long-term results on ulcer healing are unconvincing. Explanation A. Ischaemic ulcers is an indication. B. Symphathectomy is beneficial in Intemittent claudication, as it may occasionally relieve rest pain and ulcerations, when it is technically not feasible to operate or employ balloon angioplasty C. Hyperhydosis is an indication. D. Acrocyanosis is an indication. Comments Anhidrosis means that there is no sweat, which effectively means that there is already no symphathetic innervation. What is the fun in cutting the nerve (which never the less is not supplying ) Tips The other indications are Frostbite sequelae, Raynauds, TAO etc Question. 280. The Hunterian Ligature operation is performed for: A. Varicose veins. B. Arteriovenous fistulae. C. Aneurysm. D. Acute ischemiz. Answer C. Aneurysm. Ref: Surgical Short Cases by Das 2nd Edition Page 186 Quality: Spotter Status: Repeat QTDF: Surgical Short Cases by Das Discussion There are a few procedures for Arterial Aneurysm, and different names are given to denote the level of Ligation. The reader is referred to Figure 10.3 in the book Quoted above at page 186 1. Anels Method The ligature is applied just proximal to the sac 2. Brasdors Method The ligature is applied just distal to the sac 3. Hunters Method The ligature is applied immediately above a branch of a artery 4. Antylus Method The ligature is applied immediately above a branch of a artery Explanation A. Operations for Varicose veins involves names like procedures Tredenlenberg and Cockett and Dodd etc like . B. Arteriovenous fistulae is treated by Quadruple Ligation. C. Aneurysm is treated by Hunters Operation. D. Acute ischemia needs grafts and anastomosis. Comments Surgical Short Cases by Das, gives pictures for these procedures. In fact the entire chapter is worth reading Tips Question. 281. All of the following are risk factors for deep vein thrombosis (DVT) except: A. Duration of Surgery more than thirty minutes. B. Obesity. C. Age less than forty years. D. Use of the oestrogen-projesterone contraceptive pills. Answer: C. Age less than forty years. Ref: Bailey and Love 23rd Edition Page 253, Harrison 15th Edition Page 1440 Robbins-Thrombosis Quality: Reader Status: Repeat QTDF: Most books Discussion Risk factors are Age > 40 years OCPs Obesity Duration more than 30 years High Risk factors for development of DVT in Relation to Age and Duration of Surgery Urological Surgery and Age > 40 years Extensive Pelvic/Abdominal Surgery Major Orthopaedic Surgery Moderate Risk factors for development of DVT in Relation to Age and Duration of Surgery General Surgery Age > 40 years Duration > 30 minutes Age < 40, but on OCPs Low Risk factors for development of DVT in Relation to Age and Duration of Surgery Uncomplicated Surgery and Age < 40 Minor Surgery < 30 min in age < 40 Explanation A. Duration of Surgery more than thirty minutes is a risk factor. B. Obesity is a risk factor. C. Age less than forty years is not a risk factor. In fact age more than 40 years is a risk factor D. Use of the oestrogen-projesterone contraceptive pills is a risk factor. Comments Tips Question. 282. Medullary carcinoma of the thyroid is associated with which of the following syndrome: A. MEN I. B. MEN II. C. Fraumeni syndrome. D. Hashimotos thyroiditis Answer: B. MEN II. Ref: Schwartz, Page 1686 Sabiston 685 Harrison and Robbins Quality: Spotter Status: Repeat QTDF: All books Discussion Multiple Endocrine Neoplasia (MEN) Syndromes Type MEN 1 MEN 2 Mixed Syndromes MEN 2A MEN 2B Name Wermers Syndrome Sipples Syndrome Parathyroid Parathyroid hyperplasia or adenoma Parathyroid hyperplasia or adenoma Familial pheochromocytoma and islet cell tumor von Hippel-Lindau syndrome, pheochromocytoma, and islet cell tumor Neurofibromatosis with features of MEN 1 or 2 Myxomas, spotty pigmentation, and generalized endocrine overactivity in a single family Pancreas Islet cell hyperplasia, adenoma, or carcinoma Pituitary Pituitary hyperplasia or adenoma Thyroid Medullary Thyroid Carcinoma MTC Adrenal Rarely Cortical Involvement Pheochromocytoma Pheochromocytoma Others Other less common manifestations: foregut carcinoid, , subcutaneous or visceral lipomas, dermal angiofibromas or collagenomas Cutaneous lichen amyloidosis Hirschsprung disease Familial Medullary Thyroid Carcinoma Mucosal and gastrointestinal neuromas Marfanoid features Explanation A. MEN I is as given above B. MEN II is as given above C. p53 is somewhat unusual for a tumor suppressor gene in that missense mutations that produce a dominant negative protein product may also be growth-promoting, so that not all alterations obliterate function. Mutations in p53 are found in nearly half of human tumors. Germline mutations in p53 have dramatic consequences, resulting in a phenotype known as the Li-Fraumeni syndrome, where affected individuals may develop a variety of sarcomas, brain tumors, and leukemia D. In Hashimotos thyroiditis, there is a marked lymphocytic infiltration of the thyroid with germinal center formation, atrophy of the thyroid follicles accompanied by oxyphil metaplasia, absence of colloid, and mild to moderate fibrosis. In atrophic thyroiditis, the fibrosis is much more extensive, lymphocyte infiltration is less pronounced, and thyroid follicles are almost completely absent Comments Endocrinology will creep into all subjects Tips Question. 283. Radiaton exposure during infancy has been linked to which one of the following carcinoma : A. Breast. B. Melanoma. C. Thyroid. D. Lung. Answer: C. Thyroid. Ref: Bailey and Love 23rd Edition Page 727 Schwartz, Page 1681 Harrison 15th Edition Page 2590 Quality: Spotter Status: Repeat QTDF: Harrison Discussion Radiation Exposure produces Papillary Thyroid Carcinoma Explanation Self-Explanatory Comments Examples of Radiation-Induced Cancers Types of Exposure Types of Cancer Observed Neck irradiation during infancy for benign conditions Thyroid carcinoma Radiation therapy for other malignant tumors Thyroid carcinoma Breast cancer Gastric cancer Melanoma Lung cancer Sarcomas in the field Cranial irradiation Central nervous system tumors Breast irradiation for postpartum mastitis Breast cancer Brush-licking by radium dial painters Bone sarcomas Uranium mining Lung cancer In utero exposure Leukemia Tips Read the risk factors for Tumours from Robbins Question. 284. What is the most appropriate operation for a solitary nodule in one lobe of thyroid: 1.Lobectomy. 2.Hemithyroidectomy. 3.Nodule removal. 4.Partial lobectectomy with 1 cm margin around nodule. Answer: 2.Hemithyroidectomy. Ref: Bailey and Love OTS Quality: Reader Final MBBS Status: Repeat QTDF: All books give this answer - except Harrison ;-) Discussion Solitary nodule in thyroid may be adenoma ro carcinoma, which has to be differentiated by other investigations. But till then the treatment is Hemithyroidectomy !!! Explanation 1.Lobectomy can be done only for Adenoma. 2.Hemithyroidectomy is the treatment of choice. 3.Nodule removal is only for Adenoma. 4.Partial lobectectomy with 1 cm margin around nodule is done for adenoma. Comments Harrison 15th Chapter 330 Edition says Nodule removal or lobectomy as a treatment for Adenoma Tips Question. 285. What is most characteristic of congenital hypertrophic pyloric stenosis: 1.Affects the first born female child. 2.The pylori tumour is best feld during feeding. 3.The patient is commonly marasmic. 4.Loss of appetite occurs early. Answer: 2.The pylori tumour is best feld during feeding. Ref: Bailey & Love,23rd Edition Page 899 Quality: Reader Status: Probably the most Repeated Question dealing with a clinical condition QTDF: Bailey as well as Paediatrics Books Discussion Congenital Hypertrophic pyloric stenosis, as the name suggests is the hypertrophy of pyloric musculature which leads to the stenosis of the canal. It usually presents in the first born child, 4 weeks after birth. Males are more commonly affected in the ratio of 4:1. And since there obstruction, there is vomiting and since there is obstruction at the level of pylorus, there is no bile in the vomitus, and the vomitus will contain milk. After vomiting the child is usually hungry. Though there is a weight loss, and chance of child becoming marasmic, in the present days setup, this disease is easily diagnosed and there is less chance of the child becoming marasmic. To diagnose this condition, the chil dis given a test feed and the surgeon palpates the abdomen with warm hands and the characteristic lump can be felt. . USG is the Diagnosis of Choice and the musculature adjacent to the pyloric antrum is hypertrophied. Chronic pyloric stenosis - leads to obstruction and recurrent vomiting - loss of HCL from the stomach. This loss of HCL results in Hypochloremia (due to loss of Chloride of HCL) and Alkalosis (due to loss of H+ ions of HCL) i.e Hypocholremic alkalosis The body tries to compensate and as a result, Initially the urine has a low chloride (to preserve chloride) and high bicarbonate content (to counteract alkalosis). However, the bicarbonate excretion occurs along with Sodium, so that with passage of time the patient becomes progressively hyponatremic. (also, water accompanies, so dehydration occurs) Dehydration stimulates a phase of sodium retention, and while preserving the sodium, the excretion of potassium and hydrogen ions is increased. As a result the urine (in chronic cases) becomes paradoxically ACIDIC, and there is hypokalemia. Explanation 1.Affects the first born male child. 2.The pylori tumour is best feld during feeding and this is the test. 3.The patient is commonly not marasmic as the early diagnosis and intervention will same the child, even though there are chances for the choild to become marasmic. 4.Loss of appetite does not occur and the child is hungry Comments Treatment is by Ramsteds Operation, Pyloromyotomy Tips There are a few Paediatric Surgical Conditions and all them are asked repeatedly. The others being, TE Fistula, Hiatus Hernia, Anorectal malformations, hypospadiasis, epispadiasis etc Question. 286 A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation the following : A. Omental bursa [lesser sac]. B. Greater sac. C. Right subphrenic space. D. Hepatorenal space [pouch of Morison]. Answer: A. Omental bursa [lesser sac]. Ref: BDChaurasia Vol 2 Page 194 Oxfprd Text book of Surgery page 2nd Edition 1302 Bailey and Love 23rd Edition Page 911 Quality: Reader Status: New QTDF: All books Discussion Please note that The question is the question paper does not ask what is the common collection in Omental bursa or what percentage of Gastric perforation collects in Omental bursa. The question is A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initila localized peritonitis It is clearly given in Bailey and Love in the chapter of Stomach that the posterior perforations collect in Omental Bursa............... Explanation Self-Explanatory Comments Please read the question carefully. Even though the commonest collection in Omental Bursa is something else (Find it by your self!!!) and the commonest collection of Gastric Ulcer is not in Lesser Sac, by all means the answer for this question is Lesser Sac. Tips Question. 287. Which of the following is most suggestive of neonatal small bowel obstruction: 1.Generalised abdominal distension. 2.Failure to pass meconeum in the first 24 hours. 3.Bilious vomiting. 4.Refusal of feeds. Answer: 3.Bilious vomiting. Ref: Bailey and Love 23rd Edition Page 1059 Schwartz 17th Edition Page 1728 Quality: Reader Status: Repeat QTDF: Bailey Discussion Vomiting due to obstruction of the small intestine usually begins on the 1st day of life and is frequent, persistent, usually nonprojectile, copious, and, unless the obstruction is above the ampulla of Vater, bile-stained; it is associated with abdominal distention, visible deep peristaltic waves, and reduced or absent bowel movements. Malrotation with obstruction from midgut volvulus is an acute emergency that must be considered. Upright roentgenographic films of the abdomen will show the distribution of air in the intestine and often aid in locating the site of the obstruction; malrotation may be identified by contrast studies. Explanation 1.Generalised abdominal distension is a non specific finding in infants and that could be due to a lot of reasons. In fact the most reliable finding of Acute Appendicitis is Generalised Abdominal distension 2.Failure to pass meconeum in the first 24 hours is not necessarily due to obstruction. Could be even Hirshsprung 3.Bilious vomiting is the sign most suggestive of NeonatalObstruction. 4.Refusal of feeds is usually n indicator of systemic diseases. Comments Infants and children with bowel obstruction suffer from intestinal block and loss of fluid and electrolytes. Those with strangulating vascular obstruction may also manifest intestinal ischemia with sepsis and shock. Initial treatment must be directed at fluid resuscitation and stabilizing the patient. Nasogastric decompression usually provides relief of pain and vomiting. After appropriate cultures, broad-spectrum antibiotics are usually started in neonates with bowel obstruction and those with suspected strangulating infarction. Patients with strangulation must have immediate surgical relief before the bowel infarcts, resulting in gangrene and intestinal perforation. Extensive intestinal necrosis results in short-gut syndrome. Nonoperative conservative management is usually limited to children with suspected adhesions or inflammatory strictures that may resolve with nasogastric decompression or anti-inflammatory medications. If clinical signs of improvement are not evident within 12{-24 hr, then operative intervention is usually indicated Tips Small bowel Obstruction Pain & Vomiting Large Bowel Obstruction - Distention Question. 288. A 70-year-old male patient presented with history of chest pain and was diagnosed to have coronary artery disease. During routine evaluation, an ultrasound of the abdomen showed presence of gall bladder stones. There was no past history of biliary colic or jaundice. What is the best treatment advice for such a patient for his gallbladder stones? A. Open cholecystectomy. B. Lapaoscopic cholecystectomy. C. No surgery for gallbladder stones. D. ERCP and removal of gallbladder stones. Answer: C. No surgery for gallbladder stones. Ref: Bailey and Love 23rd Edition Page 975 Harrison 15th Edition Page 1781 Quality: Thinker Status: Repeat QTDF: Most books say this Discussion Presence of Gall stones per se is not an indication for Surgery in a normal patient. This patient is asymptomatic as well as having history of CAD Explanation Self Explanatory Comments Although laparoscopic cholecystectomy is the standard method for treating patients with symptomatic cholelithiasis or those with complications of cholelithiasis, other treatments may be useful in selected patients. Oral Dissolution Therapy. The oral administration of the bile acids chenodeoxycholic acid (CDCA) or ursodeoxycholic acid (UDCA) dissolves predominantly cholesterol gallstones in selected patients. At therapeutic dosages, CDCA causes diarrhea, induces transient abnormalities in liver function tests, and increases the concentration of serum low-density lipoprotein cholesterol in some patients, whereas UDCA is free of side effects and has therefore become the preferred oral agent. The stones must be radiolucent in a gallbladder that functions on oral cholecystography. The results are related to the initial size of the stones. Radiolucent gallstones less than 15 mm. in diameter will dissolve in up to 40% of patients within 2 years; longer therapy does not increase efficacy. Approximately 15% of patients will require cholecystectomy during therapy, and gallstones recur in approximately 50% of patients within 5 years without prophylaxis. The ideal candidate for oral dissolution is a thin, young female who has a small number of small, floating stones. Oral dissolution therapy may be useful in selected symptomatic patients who are unwilling to undergo laparoscopic cholecystectomy or who have precluding risk factors. Contact Dissolution Therapy. Methyl tert-butyl ether is a potent lipid solvent that dissolves gallstones within hours when introduced into the gallbladder through a pigtail catheter appropriately positioned under local anesthesia by an experienced radiologist. An automatic infusion-withdrawal device prevents overflow into the duodenum and washes the gallbladder free of debris as the stones disintegrate. Extracorporeal Shock Wave Lithotripsy. The procedure was less efficacious in patients who had larger or multiple stones. Tips Please make a list of other possible conditions and the surgeries indicated. You might get a question from this topic with the same choices but a different condition Question 289. An increased incidence of cholangiocarcinoma is seen in all ofthe following, except: A. Hydatid cyst of liver. B. Polycystic disease of liver. C. Sclerosing cholangitis. D. Liver flukes. Answer: A. Hydatid cyst of liver. Ref: Harrisons, 15th, Page 590 Bailey 23rd Page 986 Quality: Reader Status: New QTDF: Bailey Discussion Risk Factors for Cholangiocarcinoma are 1. Chronic Hepatobiliary Parasitic Infections Liver Flukes 2. Congenital Anomalies with Ectatic Ducts Choledochocyst / Carolies Disease 3. Polycystic Liver 4. Congenital Hepatic fibrosis 5. Sclerosing Cholangitis 6. Chronic Ulcerative Colitis 7. Occupational Exposure Explanation Self-Explanatory Comments Cholelithiasis is NOT a risk Factor Tips Question 290. Strong correlation with colorectal cancer is seen in: A. Peutz-Jeghers polyp. B. Familial polyposis coli. C. Juvenile polyposis. D. Hyperplastic polyp. Answer: B. Familial polyposis coli. Ref: Harrisons, 15th Edition Page 582 Quality: Spotter Status: Repeat QTDF: All books Discussion Dominantly inherited colon cancer is sometimes associated with familial polyposis, which is usually due to mutations in the adenomatous polyposis coli (APC) tumor suppressor gene on chromosome 5 Hereditable (Autosomal Dominant) Gastrointestinal Polyposis Syndromes Syndrome Distribution of Polyps Histologic Type Malignant Potential Associated Lesions Familial adenomatous polyposis Large intestine Adenoma Common None Gardners syndrome Large and small intestine Adenoma Common Osteomas, fibromas, lipomas, epidermoid cysts, ampullary cancers, congenital hypertrophy of retinal pigment epithelium Turcots syndrome Large intestine Adenoma Common Brain tumors Nonpolyposis syndrome (Lynch syndrome) Large intestine (often proximal) Adenoma Common Endometrial and ovarian tumors Peutz-Jeghers syndrome Small and large intestines, stomach Hamartoma Rare Mucocutaneous pigmentation; tumors of the ovary, breast, pancreas, endometrium Juvenile polyposis Large and small intestines, stomach Hamartoma, rarely progressing to adenoma Rare Various congenital abnormalities Explanation A. Peutz-Jeghers polyp is Rarely Malignant. B. Familial polyposis coli is Premalignant. C. Juvenile polyposis rarely progresses to Adenoma. D. Hyperplastic polyp is usually not premalignant. Comments Most colorectal cancers, regardless of etiology, arise from adenomatous polyps. A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as a nonneoplastic hamartoma (juvenile polyp), a hyperplastic mucosal proliferation (hyperplastic polyp), or an adenomatous polyp. Only adenomas are clearly premalignant, and only a minority of such lesions ever develop into cancer. Tips Occasionally, patients with Gardners syndrome develop premalignant adenomas in the small bowel; such lesions are generally in the duodenum. Multiple polypoid tumors may occur throughout the small bowel (and occasionally the stomach and colorectum) in the Peutz-Jeghers syndrome Question. 291. A 50-year old male. Working as a hotel cook, has four dependent family members. He has been diagnosed with an early stage squamous cell cancer of anal canal. He has more than 60% chances of cure. The best treatment option is: A. Abdomino-perineal resection. B. Combined surgery and radiotherapy. C. Combined chemotherapy and radiotherapy. D. Chemotherapy alone. Answer: C. Combined chemotherapy and radiotherapy. Ref: Bailey and Love 23rd Edition Page 1141 Quality: Reader Status: Repeat QTDF: Bailey Discussion Tumors arising in the anal canal or in the transitional zone that have a u squamous, u basaloid, u cloacogenic, or u mucoepidermoid epithelium share a similar clinical presentation, response to treatment, and prognosis and are considered collectively. They typically present as u a mass, sometimes with u bleeding and u pruritus. At the time of diagnosis, u 50% are less than 3 cm. in size, and the rest are larger. u Nearly a quarter are superficial or in situ. In the past, treatment modalities included either surgery alone or radiation alone. Patients with u tumors confined to epithelial or subepithelial tissue have been treated by local excision, and patients with u more advanced lesions by abdominoperineal resection. u for superficial, early-stage lesions, local excision alone remains a good option. u Patients with lesions greater than 2 cm. with any suggestion of fixation or sphincter involvement on digital examination or anal ultrasonography should not be treated by local excision. Thus, the majority of patients who are not candidates for local excision are best treated by combined chemotherapy and radiation therapy Explanation WE see that for superficial lesions, local excision alone is suffice, but since that is not given as one of the choices, we go for Chemoradiation as the answer Comments The introduction of multimodality therapy, combining radiation and chemotherapy, promised to preserve continence, avoid colostomy, and offer similar survival advantages. Tips External irradiation: 3000 cGy. to primary tumor and pelvic and inguinal nodes. Start day 1 (200 cGy./day) Systemic chemotherapy: 1. 5-fluorouracil: 1000 mg./sq. m. for 24 hours as a continuous infusion for 4 days. Start day 1. 2. Mitomycin C: 15 mg./sq. m. intravenous bolus. Day 1 only. 3. 5-fluorouracil: Repeat 4-day infusion. Start day 28. Question. 292. A 10-mm calculus in the right lower ureter associated with proximal hydrouretero-nephrosis is best treated with: A. Extracorporeal shockwave lithotripsy. B. Antegrade percutaneous access. C. Open ureterolithotomy. D. Ureteroscopic retrieval. Answer: D. Ureteroscopic retrieval. Ref: Bailey & Love 23rd Edition Page 1189 Quality: Reader Status: Repeat QTDF: Bailey Discussion Methods for Removal are Ureteroscopic Removal Small stone Stone in lower part of Ureter within 5-6 cm of ureteric orifice Extracorporal Shock Wave Lithotripsy Proximal stones Mid ureter stones are pushed up and then exposed to shock waves Stones less than 2 to 2.5 cm Percutaneous Nephrolithotripsy For proximal Ureteral Calculi Stones more than 2.5 cm Stones that are resistant to shock wave Open UrethroLithotomy For long standing cases Explanation Self Explanatory Comments Regular Question Tips Indications for Stone Removal (Mnemonic POLICE) Passive - Stone is stationary Obstruction -Causing obstruction Large Stone too large to pass Infection Colic - Repeated Attacks of Colic Enlarging - Stone is increasing in size Question. 293. A 65-year-old male smoker presents with gross total painless hematuria. The most likely diagnosis is: A. Carcinoma urinary bladder. B. Benign prostatic hyperplasia. C. Carcinoma prostate. D. Cystolithiasis. Answer: A. Carcinoma urinary bladder. Ref: Bailey & Love 23rd Edition Page 1229 Quality: Reader Status: Repeat QTDF: Bailey Discussion Painless Hematuria is Ca Bladder Unless Proved otherwise. In this patient, The other findings favouring the diagnosis are 65 years Male Smoker Explanation Self Explanatory Comments About Bladder Carcinoma MC Type Transitional Cell Carcinoma From Urachus Adenocarcinoma Due to Schistosomiasis Squamous Cell Carcinoma Tips Please read the predisposing factors Question. 294. Semen analysis of a young man who presented with primay infertility revealed low volume, fructose negative ejaculate with azoospermia. Which of the following is the most useful imaging modality to evaluate the cause of his infertility? A. Colour duplex ultrasonography of the scrotum. B. Transrectal ultrasonography. C. Retrograde urethrography. D. Spermatic venography. Answer: B. Transrectal ultrasonography. Ref: Sabiston 15th Edition Page 1556 Oxford Trextbook of Surgery Quality: Thinker Status: New QTDF: Sabiston / Oxford Discussion Physical examination of the infertile male should include careful examination of the genitalia, particularly to ensure the testes are of normal size and consistency, the epididymides and vasa are present, and there is no evidence of chronic inflammatory disease of the external genitalia. Prostatitis should be ruled out by digital examination, prostatic massage, and examination of the prostatic fluid. Appropriate cultures constitute the basis for antibiotic therapy, which is sometimes effective in alleviating chronic inflammatory processes as the cause of infertility. Other diagnostic modalities such as cystourethroscopic, ultrasonographic, and radiographic studies of the ejaculatory ducts, vasa, and seminal vesicles are occasionally helpful to identify obstructive problems in the transport system. Laboratory studies that are helpful in the evaluation of infertility include complete semen analyses, usually obtained after a 3-day absence of sexual activity. The same sample can be tested for fructose, the absence of which would suggest either obstruction of the seminal vesicles or their absence. Serum levels of luteinizing hormone, follicle-stimulating hormone, and testosterone are helpful to identify pregonadal, gonadal, and postgonadal reasons for infertility. The Table in Oxford Text book of Surgery dealing with infertility clearly says that Fructose Negative Azoospermia is Obstruction of Ejaculatory duct or Atresia of Vas or Seminal Vesicle Occasionally, pelvic computed tomography in association with vasography identifies an abnormal seminal vesicle. Transrectal ultrasound : Transrectal ultrasound with 5 to 7 MHz transducers can give detailed images of prostatic zonal anatomy. Most peripheral zone tumours appear hypoechoic (Fig. 1) 1595 due to replacement of stroma by tumour. As a screening tool, however, transurethral ultrasound is limited by the fact that only one-third of hypoechoic lesions are cancer and that up to 40 per cent of prostate cancers are isoechoic and therefore not detected. This method will, however, detect twice as many tumours as digital rectal examination alone. Staging localized lesions with transrectal ultrasound results in the same over- and understaging as is seen with digital rectal examination. The primary advantage of transrectal ultrasound is its ability to guide a biopsy needle directly, either to an area of suspicion (nodule, seminal vesicle) or to perform six spaced mapping; biopsies, as advocated by Stamey. The the question clearly states Ejaculatory Duct Obstruction, Atresia of Vas or Seminal Vesicle There are 2 investigations for the Obstructive pathology(Seminal Vesicles) 1. Transrectal USG 2. Pelvic CT with Vasography.. Of this we have got only Transrectal USG in our choice.. So the answer can be well Choice 2 And we can very well rule out choices 1 and 4 as they are for testicular cause.. which is done only in case of fructose + azoospermia. Explanation A. Colour duplex ultrasonography of the scrotum is for Testicular cause of Azoospermia, which is done for Fructose positive Azoospermia. B. Transrectal ultrasonography is the Ideal Investigation for this patient. C. Retrograde urethrography is iused to assess Uretheral Structural defects. D. Spermatic venography is for Testicular cause of Azoospermia, which is done for Fructose positive Azoospermia Comments Organ Procedure Seminal Vesicle and Ejaculatory Duct Vasography Transrectal USG Pelvic CT Testes USG Scrotum Testicular Veins, PampiniformPlexus Spermatic Venography Urethera Retrograde Uretherography Tips Question. 295. A 70 year old patient with benign prostatic hyperplasia underwent transurethral resection of prostate under spinal anaesthersia. One hour later, he developed vomiting and altered sensorium. The most probable sause is: A. Over dosage of spinal anaesthetic agent. B. Rupture of bladder. C. Hyperkalemia. D. Water intoxication Answer D. Water intoxication Ref: Bailey & Love, 23rd Edition Page 1247 Quality: Reader Status: Repeat QTDF: Bailey Discussion Symptoms and signs of water intoxication may include mild headache, confusion, anorexia, nausea, vomiting, coma, and convulsions. Explanation A. Over dosage of spinal anaesthetic agent. Hardly causes vomiting, but may lead to respiratory arrest B. Rupture of bladder does not occur one hour after TURP. It occurs during the procedure. And the patient may go into a state of shcok C. The most serious effect of hyperkalemia is cardiac toxicity (see questions on Hyperkalemia) D. The clinical scenario given is the classic description of Water intoxication Comments Now a days the oncidence of Water Intoxication is reduced with the use of 1. 5 % IsotonicGlycerine or Normal Saline Tips The involuntary movement occurring in Water Intoxication is Athetosis Question. 296. Which of the following lasers is used for treatment of bening prostatic hyperplasia as well as urinary calculi? A. CO2 laser. B. Excimer laser. C. Ho: YAG laser. D. Nd: YAG laser. Answer: C. Ho: YAG laser. Ref: Bailey and Lover 23rd Edition Page 1247 Sabiston 15th Edition Chapter 14 Quality: Spotter Status: New QTDF: Bailey Discussion Ho:YAG Laser. The holmium laser has a wavelength of 2.1 nm. and is highly absorbed by water. With this instrument one can vaporize, cut, coagulate, smooth, and sculpt tissue. This method is gaining wide acceptance among orthopedic surgeons as a useful arthroscopic surgical tool. It has a minimal amount of thermal necrosis and is able to cut and ablate tissues with great ease Explanation A. CO2 laser is used for burn wound excision. The CO2 laser produces its effect through instantaneous heating of intracellular water to boiling, exploding cells in its pathway. Some surgeons to cut tissue use it. Laser heating generates steam and carbonization of tissues. The laser creates a 0.1-mm. zone of histologic necrosis, which is equivalent to that of the scalpel. The superior hemostatic effect of the laser scalpel makes it especially suitable for massive surgical excision; electrosurgical excision has 1.67 times the blood loss of laser excision. Most comparative studies performed in the animal model as well as in the clinical setting prove that the CO2 laser is not superior to electrosurgery in postoperative adhesion formation. The infection-potentiating effect of the laser scalpel militates against its use in incisional surgery. B. Excimer laser is used for LASIK. Please see the question on Lasik in Ophthalmology C. Ho YAG Laser is used in treatment for BPH (Coagulation) as well as for Treatment for Calculi. It is effective in all types of stones, regardless of the content. D. Nd:YAG Laser. Forward penetration of the laser beam is least with the argon laser, intermediate with the CO 2 laser, and deepest with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, with the Nd:YAG laser energy (1060 nm.) providing destructive coagulation effects on tissues. The Nd:YAG laser can direct light energy through a flexible quartz fiber, permitting the use of the fiberoptic endoscope in the paranasal sinuses and tracheobronchial tree. Comments Argon Laser. Argon lasers result from the emission of a monochromatic beam of blue-green light (488 to 514 nm) that can be highly focused. The energy is absorbed by red cell hemoglobin and transformed to heat, creating superficial thermal injury. Argon lasers have for years been the mainstay of ophthalmologic treatment and prevention of intraocular hemorrhage. Extensive experimental efforts support the potential benefits of laser fusion of tissue. The proposed advantages include speed, improved healing without the foreign body reaction associated with sutures, and reduction of intimal hyperplasia that is often seen in the region of sutured anastomoses. Exciting preliminary results have concluded that fusion of the vascular tissue with the argon laser is possible in humans. Reliable primary sealing of the vascular anastomosis is achieved. In addition, laser thermal arterial recanalization is an effective adjunct to balloon angioplasty. Er:YAG Laser. The erbium laser has a wavelength of 2.94 nm. The wavelength is very strongly absorbed by the water component of tissue, and it can easily vaporize cartilage, fibrous tissue, and bone. It has a very shallow depth of penetration and affords extreme surgical precision. KTP Laser. The potassium-titanyl-phosphate (KTP) laser, with a wavelength of 0.532 nm., is a high-frequency pulsed laser. It can be transmitted by fiberoptics and can be used in an aqueous medium. The green light of KTP recognizes red and black pigments and is well absorbed by hemoglobin and melanin. It is considered a superficial photocoagulator (0.2 to 2 mm.), and it is useful for tissue cutting, coagulation, and disc ablation. Tunable Dye Laser. The modern tunable dye laser (577 nm.) provides excellent results in the difficult treatment of port-wine stains. The Cavitron ultrasonic surgical aspirator (CUSA knife) is an ultrasound probe that functions as an acoustic vibrator. The instrument selectively fragments and aspirates tissue of high water and low collagen content (i.e., tumors), sparing other tissues such as blood vessels and nerves. The Cavitron aspirator was introduced into clinical use in 1967 for phacoemulsification of cataracts, and a more powerful version was approved for use in neurosurgery in 1976. The ability to remove a tumor without causing adjacent brain tissue trauma due to suctioning, coagulation, or manipulation has been greatly augmented with the development of the Cavitron. Advantages of reduced blood loss, reduced tissue injury, and improved visibility are significant compared with the scalpel or cautery. The main advantages of the Cavitron aspirator over the laser are the rapidity with which it can debulk large volumes of a tumor and the fact that it does not produce a char as it resects. This device is being used increasingly for a wide range of procedures, such as partial hepatectomy, pancreatectomy, nephrectomy, splenectomy, hemiglossectomy, mucosal proctectomy, vulvectomy, and cytoreduction of ovarian cancer, and in resection of spinal cord and brain stem tumors Tips Treatment of BPH with relevance to Endocrinology is an area commonly asked Question. 297. Which of the following is an absolute indication for surgery in cases of benign prostatic hyperplasia: A. Bilateral hydroureteronephrosis. B. Nocturnal frequency. C. Recurrent urinary tract infection. D. Voiding bladder pressures> 50 cm of water. Answer: A. Bilateral hydroureteronephrosis. Ref: Bailey and Love 23rd Edition Page 1241, 1243 Schwartz 17th Edition Page 1787 Quality: Reader Status: New QTDF: Bailey / Schwartz Discussion Indications for Surgery in a Case of BPH 1. Symptoms of Prostatism 2. Haemorrhage 3. Acute Retention of Urine 4. Chronic Retention of Urine a. Residual Urine > 200 ml b. Raised Blood Urea or Serum Creatinine c. Hydroureter or Hydronephrosis 5. Complicated by BOO a. Stone b. Recurrect UTI c. Diverticulum Explanation A. Bilateral hydroureteronephrosis. Is an indication B. Nocturnal frequency per se is not an indication. C. Recurrent urinary tract infection is an indication , but is less sevre thatn Bilateral hydonephrosis. D. Voiding bladder pressures> 50 cm of water is not an absolute indication. The normal pressure is 60 cm of Water. And only Pressures above 180 cm of Water are considered as severe disease. Comments Tips Question. 298. The commonest cause of an obliterative stricture of the membranous urethra is: A. Fall-astride injury. B. Road-traffic accident with fracture pelvis and rupture urethra. C. Prolonged catheterization D. Gonococcal infection. Answer: B. Road-traffic accident with fracture pelvis and rupture urethra. Ref: Bailey and Love 23rd Edition Page 1261 Status: Reader QTDF: ??? Discussion Penetrating injuries of the urethra are also observed, most commonly due to gunshot or stab wounds. Immediate urethral reconstruction and urinary diversion by suprapubic cystostomy are appropriate. Similarly, straddle injuries to the perineum may cause urethral rupture on the ventral surface, which usually demands prompt surgical intervention and urethral stenting with a fenestrated catheter for at least 7 to 10 days. Iatrogenic perforation or rupture of the urethra may occur in the course of instrumentation, cystoscopy, or urethral dilation. Pre-existing urethral strictures due to trauma or gonococcal urethritis predispose to difficult instrumentation and potential perforation of the urethra, often followed by the establishment of a urethral diverticulum or false urinary passage. Periurethral abscesses and attendant complications may ensue unless urethral injury of this sort is recognized and promptly treated. In the incidence of iatrogenic injury, suprapubic cystostomy or urinary diversion should be initiated along with an antibiotic. Explanation A. Fall-astride injury is the most common cause of stricture bulbous urethera. B. Road-traffic accident with fracture pelvis and rupture urethra. C. Prolonged catheterization may involveany part of urethera D. Gonococcal infection commonly involves bulbous urethera. Comments Tips Question. 299. The best time for surgery of hypospadias is: A. 1-4 months of age. B. 6-10 months of age. C. 12-18 months of age. D. 2-4 years of age. Answer: B. 6-10 months of age. C. 12-18 months of age. D. 2-4 years of age. Ref: Surgical Short Cases by Das 2nd Edition Page 338 First Stage between 1 and 2 years and second stage between 5 to 7 years Nelsons Paediatrics 15th Edition Chapter 496 before 18 months Quality: Confusa Status: Repeat, but with ambigous selection of choices QTDF: ???? Discussion The treatment of hypospadias starts in the newborn period. Routine circumcisions should be avoided, as the foreskin is often essential for repair later in life. Mild cases of hypospadias are usually repaired for cosmetic reasons alone, but with increasing severity repair becomes essential in order to allow the child to void standing, to allow future normal sexual function, and to avoid psychologic consequences of having malformed external genitalia. The ideal age for repair is before the age of 18 mo. Most of these anomalies can now be repaired in a single operation with minimal hospitalization; accordingly, emotional trauma is less likely or severe now than with the older techniques. Repair of hypospadias is a technically demanding operation and should be performed by surgeons with extensive experience. Few more points Operated by the time the preputial tissue is fully developedand before the boy goes to school Pediatric Urology textbooks & Ashcraft ( U.K. bible of Pediatric surgeons) & Ravitchs textbooks on Pediatric surgery u They state the best time to be between 6 mo & 1 year u Till 6 months there are anesthetic risks u After 1 yr there are problems in managing a toddler u Cosmetic & functional outcomes are also good OHCS states the age is 2-4yrs. Explanation What is to be explained here J Comments The best time for surgery for hypospadias is All except 1 to 4 months ;-) Tips Though Hypospadias is a common topic, it is a dreaded area as for as MCQs are concerned because most questions have 2 answers. Example the most common variety is Galandular / Coronal !!!! Question. 300. A 27 year old man presents with a left testicular tumor with a 10 cm retroperitoneal lymph node mass. The treatment of choice is A. Radiotherapy. B. Immunotherapy with interferon and interleukins. C. Left high inguinal orchiectomy plus chemotherapy. D. Chemotherapy alone. Answer: C. Left high inguinal orchiectomy plus chemotherapy. Ref: Sabiston Chapter 46 Bailey and Love 23rd Edition Page 1280 Harrison 15th Edition Page 617 Quality: Thinker Status: Repeat QTDF: All books Discussion If diagnosis of testicular neoplasm is confirmed, high inguinal orchiectomy is accomplished, removing the entire cord with the involved testis and leaving the stump of the cord within the retroperitoneum. Multiagent chemotherapy protocols rather than retroperitoneal node dissection appear to be the treatment of choice in this disease A variety of chemotherapeutic agents have been developed over the past few years, resulting in dramatic responses. Historically, the antitumor agents have included dactinomycin, methotrexate, and chlorambucil. Some activity has also been noted with vinblastine. Cisplatin, bleomycin, and vinblastine with the addition of etoposide are now considered to be the primary therapeutic agents. Explanation A. Radiotherapy is not used. B. Immunotherapy with interferon and interleukins is not superior to Orchidectomy. C. Left high inguinal orchiectomy plus chemotherapy is the most favoured regime. D. Chemotherapy alone will be less effective Comments The management is dependent of the staging Stage I Tumour Limited to Testes, Epididymis and Spermatic Cord Seminoma Radiation Non Seminomatous Tumours RPLND / Observation Stage II Tumour Limited to Retroperitonael Lymph Nodes u Stage II a <2 cm Seminoma Radiation Non Seminomatous Tumours RPLND or Chemotherapy followed by RPLND u Stage II b 2 5 cm Seminoma Radiation Non Seminomatous Tumours RPLND +/- Chemotherapy u Stage II c > 5 cm Seminoma Chemotherapy Non Seminomatous Tumours Chemotherapy Stage III Tumour Outside RPLN involving supra diaphragmatic nodes or Viscera Seminoma Chemotherapy Non Seminomatous Tumours Chemotherapy Tips 0񄋋D_-kD'|x%A\Pb0񄋋D_-kD'|x%A\Pb0Pp0PP 0񄋋D_-kD'|x%A\Pb '\P-kDlGáD*w-kDLD*w-kH!0߸pP0PP 0񄋋D_-kD'|x%A\Pb0񄋋D_-kD'|x%A\Pb0Pp0PP 0񄋋D_-kD'|x%A\Pb '\P-kDlGáD*w-kDLD*w-kH!0߸pP0PP 0񄋋D_-kD'|x%A\Pb0񄋋D_-kD'|x%A\Pb0Pp0PP q0񄋋D_-kD'|x%A\Pb '\P-kDlGáD*w-kDLD*w-kH!0߸pP0PP 0񄋋D_-kD'|x%A\Pb0񄋋D_-kD'|x%A\Pb0Pp0PP  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No active management as heparin action disappears in few hours 2. Protamine if there is still bleeding. ALL Medical and Pharmacological Books say this Blood Loss is managed by 1. Whole blood transfusion - Tripathi as above The question asks management of bleeding...... the answer is obviously Protamine Tips Heparin is an enzyme activator, where as most of the drugs we use are Enzyme Inhibitors. Another enzyme activator is P2AM. Forskalin activates adenylate cyclase etc. 222. Bacitracin acts on: A. Cell Wall B. Cell Membrane. C. Nucleic Acid. D. Ribosome. Answer: A (Cell Wall) Ref: Katzung, 7th edn, 739; KDT 5th edn, 693 & 4th edn, 672 to 673 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this Discussion Bacitracin acts by inhibiting cell wall synthesis at a step earlier than that inhibited by penicillins. It is a polypeptide and a topical agent. It is got from Bacillus Subtilis Explanation A. Bacitracdin acts on the Cell Wall B. Antifungals act on Cell Membrane. C. Drugs like Ciprofloxacin act on Nucleic Acid. D. Drugs like Tetra cycline act on the Ribosome. Comments The various drugs acting in the cell wall however act at different levels Tips As always the question are from Anti group of drugs; Anti Epilepsy, Anticholinergics Antituberculous, AntiLeprosy, Anti Malarial, Antifungal, Antibiotics, and Anti Histaminics 223. All of the following drugs act on cell membrane, except: A. Nystatin. B. Griseofulvin. C. Amphotericin B. D. Polymixin B. Answer: B (Griseofulvin) Ref: KDT 5th edn, 693 & 4th edn, 672 to 673 & 774 Quality: Spotter Status: Repeat QTDF: All Pharmac books give this Discussion Cell wall synthesis inhibition Penicillins Cephalosporins Cycloserine Vancomycin Bacitracin Cell membrane leakage POLY PEPTIDES: Polymyxins, POLY PEPTIDES: Colistin POLYENES: Amphotericin B, POLYENES: Nystatin, POLYENES: Hamycin Protein synthsis inhibition Tetracyclines Chloramphenicol Macrolides - erythromycin Clindamycin mRNA misreading Aminoglycosides DNA gyrase inhibition Fluroquinolones DNA function inhibtion Metronidazole, Rifampicin DNA synthesis inhibition Acyclovir, Idoxuridine, Ziovudine Intermediary metabolism inhibition Sulphonamides, Trimethoprim Pyrimethamine Ethambutol PAS Explanation A. Nystatin [Katzung-786] produces micropores in the fungal cell membrane B. Griseofulvin [Katzung-785] interfere with Mitosis C. Amphotericin B [Katzung-780] produces micropores in the fungal cell membrane D. Polymyxin B [Katzung-804] produces pseudopores in the bacterial cell membrane Comments Mechanism of Action of Antibiotics is a favoured topic Tips Read the classification in Page 672 to 673 KDT 4th Edition 224. The most effective drug against M. leprae is: A. Dapsone. B. Rifampicin. C. Clofazamine. D. Prothionamide. Answer: B (Rifampicin) Ref: Harrisons, 15th edn, 1039; KDT 5th edn, 711 & 4th edn, 766 Status: Repeat QTDF: KDT Discussion Established agents used to treat leprosy include 1. dapsone (50 to 100 mg/d), 2. clofazimine (50 to 100 mg/d, 100 mg three times weekly, or 300 mg monthly), and 3. rifampin (600 mg daily or monthly). Of these drugs, only rifampin is bactericidal. The sulfones (folate antagonists), the foremost of which is dapsone, were the first antimicrobials found to be effective for the treatment of leprosy and are still the mainstay of therapy. With sulfone treatment, skin lesions resolve and numbers of viable bacilli in the skin are reduced. Although primarily bacteriostatic, dapsone monotherapy results in only a 10% resistance-related relapse rate; after 18 years of therapy and subsequent discontinuation, only another 10% of patients relapse, developing new, usually asymptomatic, shiny, histoid nodules. Dapsone is generally safe and inexpensive. Individuals with glucose-6-phosphate dehydrogenase deficiency who are treated with dapsone may develop severe hemolysis; those without this deficiency also have reduced red cell survival and a hemoglobin decrease averaging 1 g/dL. Dapsones usefulness is limited occasionally by allergic dermatitis and rarely by the sulfone syndrome (including high fever, anemia, exfoliative dermatitis, and a mononucleosis-type blood picture). It must be remembered that rifampin induces microsomal enzymes, necessitating increased doses of medications such as glucocorticoids and oral birth control regimens. Clofazimine is often cosmetically unacceptable to light-skinned leprosy patients because it causes a red-black skin discoloration that accumulates, particularly in lesional areas, and makes the patients diagnosis obvious to members of the community. Other antimicrobial agents active against M. leprae in animal models and at the usual daily doses used in clinical trials include ethionamide/prothionamide; the aminoglycosides streptomycin, kanamycin, and amikacin (but not gentamicin or tobramycin); minocycline; clarithromycin; and several fluoroquinolones, particularly ofloxacin. Next to rifampin, minocycline, clarithromycin, and ofloxacin appear to be most bactericidal for M. leprae, but these drugs have not been used extensively in leprosy control programs. Explanation A. Dapsone is the mainstay. B. Rifampicin is the most effective. C. Clofazamine is also used. D. Prothionamide, a congener of ethionamide that is not available in the United States, has pharmacologic properties similar to those of ethionamide and is widely used throughout the world.. Comments Rifampicin is most effective as it is cidal, Dapsone is the mainstay Tips While ethionamide (250 mg/d) has not been approved by the FDA for the treatment of leprosy, it is sometimes used in the United States in combination with rifampin (600 mg/d) to treat dapsone-resistant leprosy in patients who cannot accept the skin-depigmentation effect of clofazimine. Because resistance to ethionamide develops quickly when the drug is used alone, it must be used with other effective agents. Patients should be monitored closely for hepatotoxicity when taking ethionamide (especially in combination with rifampin), and treatment should be discontinued if the patients ALT levels exceed 2.5 times the normal value. bosis (DVT) except: A. 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Nonoperative conservative management is usually limited to children with suspected adhesions or inflammatory strictures that may resolve with nasogastric decompression or anti-inflammatory medications. If clinical signs of improvement are not evident within 12{-24 hr, then operative intervention is usually indicated Tips Small bowel Obstruction Pain & Vomiting Large Bowel Obstruction - Distention Question. 288. A 70-year-old male patient presented with history of chest pain and was diagnosed to have coronary artery disease. During routine evaluation, an ultrasound of the abdomen showed presence of gall bladder stones. There was no past history of biliary colic or jaundice. What is the best treatment advice for such a patient for his gallbladder stones? A. Open cholecystectomy. B. Lapaoscopic cholecystectomy. C. No surgery for gallbladder stones. D. ERCP and removal of gallbladder stones. Answer: C. No surgery for gallbladder stones. Ref: Bailey and Love 23rd Edition Page 975 Harrison 15th Edition Page 1781 Quality: Thinker Status: Repeat QTDF: Most books say this Discussion Presence of Gall stones per se is not an indication for Surgery in a normal patient. This patient is asymptomatic as well as having history of CAD Explanation Self Explanatory Comments Although laparoscopic cholecystectomy is the standard method for treating patients with symptomatic cholelithiasis or those with complications of cholelithiasis, other treatments may be useful in selected patients. Oral Dissolution Therapy. The oral administration of the bile acids chenodeoxycholic acid (CDCA) or ursodeoxycholic acid (UDCA) dissolves predominantly cholesterol gallstones in selected patients. At therapeutic dosages, CDCA causes diarrhea, induces transient abnormalities in liver function tests, and increases the concentration of serum low-density lipoprotein cholesterol in some patients, whereas UDCA is free of side effects and has therefore become the preferred oral agent. The stones must be radiolucent in a gallbladder that functions on oral cholecystography. The results are related to the initial size of the stones. Radiolucent gallstones less than 15 mm. in diameter will dissolve in up to 40% of patients within 2 years; longer therapy does not increase efficacy. Approximately 15% of patients will require cholecystectomy during therapy, and gallstones recur in approximately 50% of patients within 5 years without prophylaxis. The ideal candidate for oral dissolution is a thin, young female who has a small number of small, floating stones. Oral dissolution therapy may be useful in selected symptomatic patients who are unwilling to undergo laparoscopic cholecystectomy or who have precluding risk factors. Contact Dissolution Therapy. Methyl tert-butyl ether is a potent lipid solvent that dissolves gallstones within hours when introduced into the gallbladder through a pigtail catheter appropriately positioned under local anesthesia by an experienced radiologist. An automatic infusion-withdrawal device prevents overflow into the duodenum and washes the gallbladder free of debris as the stones disintegrate. Extracorporeal Shock Wave Lithotripsy. The procedure was less efficacious in patients who had larger or multiple stones. Tips Please make a list of other possible conditions and the surgeries indicated. You might get a question from this topic with the same choices but a different condition Question 289. An increased incidence of cholangiocarcinoma is seen in all ofthe following, except: A. Hydatid cyst of liver. B. Polycystic disease of liver. C. Sclerosing cholangitis. D. Liver flukes. Answer: A. Hydatid cyst of liver. Ref: Harrisons, 15th, Page 590 Bailey 23rd Page 986 Quality: Reader Status: New QTDF: Bailey Discussion GdYZGdTZGdLZGd ZGdZGd7ZGdurgery more than thirty minutes. B. 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True about calcium is/are a. Entry is regulated by calmodulin uptake b. Extracellular concentration of calcium is 10,000 times more than intracellular c. Symport uptake d. Entry into cell is passive c. Released by sarcoplasmic reticulum Ref:: ganong 35, Quality::::spotter thinker reader BATA Discussion Explanation Correct choices: b, e . C. Which of the following are organophosphates: A. dieldrin B. parathion C. malathion D. Kepone 5. Propoxur Ref::Trip 5th Page 81 Park 550 table Quality::::reader Discussion Explanation: anticholinesterases Reversible Carbamates Acridine Physostigmine (Eserine) Neostigmine Pyridostigmine Edrophonium Rivastigmine Donepezil tacrine Irreversible Organophosphates Carbamates Dyflos DFP Echothiophate Parathion Malathion Diazinon TIK 20 Tabun Sarin Soman Carbaryl (Sevin) Propoxur(Baygon) Explanation A. dieldrin-organochlorine pesticide. incorrect choice. B. parathionirreversible OPC. correct choice. C. malathion irreversible OPC. correct choice D. Kepone/chlordecone- organochlorine pesticide. incorrect choice pesticide 5. Propoxurirreversible carbamates. incorrect choice Correct choices: b c 203. Which of the following are features of spinal shock a. Spasticity b. Urinary retention c. Areflexia d. Sensory level e. Increased DTRs Ref::clinical acumen Quality::::spotter thinker reader BATA Discussion Spinal shock(neuronal) is the initial state just after an acute insult causing an UMN lesion caused by the temporary depressant effect on the anterior horn cells. Characterized by paralysis,areflexia,flaccidity,the chracteristic hypertonia and increased relexes of cotticospinal lesion appear after few hrs-days. Explanation Correct choices B C d 217. Which of the following predispose a patient to prehepatic encepalopathy a. Constipation b. Bacterial peritonitis c. Hemorrhage d. Hyperkalemia e. Dehydration Ref: HPIM 1715 Quality::::spotter thinker reader BATA Discussion Common precipitants of hepatic failure Increased nitrogen load GIT bleeding Excess dietary protein Azotemia Constipation Electrolyte & metabolic imbalance Hypokalemia Alkalosis Hypoxia Hyponatremia Drugs Narcotics and Tranqulizers Sedatives Diuretics Miscellaneous Infection surgery Superimposed acute liver disease Progressive liver disease Explanation: A. Constipation B. Bacterial peritonitis being an infection. correct choice. C. Hemorrhage D. Hyperkalemia: Hypokalemia not Hyperkalemia is known to worsen hepatic Encephalopathy. 5. Dehydration can cause hypovolemia & electrolyte disturbances that can ppt. hepatic Encephalopathy Correct choices: a b c e 8. the drugs useful in the treatment of ectopic pregnancy is A. Methotrexate B. Actinomycin D C. Cyclophosphamide D. Potassium fluoride 5. Adriamycin Ref:: Dutta 202 Quality:::: spotter Explanation A. Methotrexate: used in medical therapy. correct choice. B. Actinomycin D. correct choice. C. Cyclophosphamide. Incorrect choice. D. Potassium fluoride: potassium chloride is used in ectopic pregnancy. Incorrect choice. 5. Adriamycin is not used in ectopic pregnancy. Correct choices A b 210. Adventitial bursitis due to tuberculosis is found in which of the following sites commonly a. Prepatellar b. Greater trochanter of femur c. Sub acromial d. Metatarsal e. Sub olecranon 209. Snow ball opacities in vitreous is seen in which of the following a. Parsplanitis b. Rheumatoid arthritis c. Anterior unietis d. Retinitis pigmentosa e. Endothelial dystrophy Ref: http://www. indmedica. com/cos/journal/vasculitis. html Quality::::spotter thinker reader BATA Explanation A. Parsplanitis is characterized by snowball opacities. B. Rheumatoid arthritis is one of the causes of pars planitis hence may show snow ball opacities C. Anterior uveitis D. Retinitis pigmentosa 5. Endothelial dystrophy Correct choices: A b 77. The left border of the heart is formed by a. Pulmonary Artery b. Pulmonary vein c. Right ventricle d. Ascending aorta e. Arch of aorta Ref:: BDC 226,Grays 38th 1476 Quality:::: spotter thinker reader BATA Discussion Anatomically Right border is formed by RA. Left border of heart is formed by LA and LV. Upper border formed by LA, asc aota & pul trunk infron of it. Inferior border of the heart is formed by RV and contribution of LV at the apex. Correct choices NONE OF THE CHOICES ARE CORRECT Or 77. left border of the heart in chest XR is formed by a. pul artery b. pul vein c. abdominal aorta d. arch of aorta e. right ventricle Quality:::: :reader Ref:: Discussion: Borders of cardiac silhouette on PA view Right border from above downwards Superior vena cava Outer border of R atrium Sometimes asc, arch of aorta & inferior vena cava Left border from above downwards Aortic knuckle Pul. Trunk or L pul artery L atrial appendage outer border of L ventricle correct choice: a d 9. the resting membrane potential depends on which of the following ions A. Magnesium B. Calcium C. Potassium D. Sodium 5. Chloride Ref:: Ganong 50 Quality:::: spotter Discussion The ionic basis of RMP: Explanation A. Magnesium has no role in RMP. B. Calcium has role in action potential in muscle cells not RMP C. Potassium. The major ion whose movements produce RMP. Correct choice. D. Sodium. incorrect choice. 5. Chloride. No role. Correct choices C 79. In acute inflammation the migration of neutrophils and its attachment to endothelium is mediated by which of the follwing. a. Integrins b. Selection s c. Adhesins d. Perforins e. Opsonins Ref:: Robbins 29, 273 Quality::::spotter thinker reader BATA Explanation a. Integrins are transmembrane glycoproteins that function as cell receptors for extra cellular matrix. correct choice. b. Selectins=the loose and transient adhesions involved in rolling of leucocytes over endothelial cells are accounted for by the selectin family of molecules. E-selectin are present on on endothelial cells, P-selectin on platelets and endothelial cells and L-Selectins on leucocytes. c. Adhesins-are molecules that bind bacteria to cells e. g. lipoteichoic acid and protein F. d. Two classes of cytotoxins include perforins and granzymes. . The perforins form pores in the targets cell membranes. incorrect choice. e. Opsonins are protiens or peptides that label targets for phagocytosis by PMNs and/or macrophages. incorrect choice, Correct choices b 102. Susruta samhita was translated by a. Celsius b. harnel c. Bhargabhatta d. heslar e. Bernard Ref: http://www. ayurveda. com/online%20resource/ancient_writings. htm Quality:::: BATA Discussion: http://www. ayurveda. com/online%20resource/ancient_writings. htm Sushruta Samhita The Sushruta Samhita deals with the practice and theory of surgery, is an important source of Ayurvedic aphorisms. This work is the first to enumerate and discuss the pitta sub-doshas and the marmas. With its emphasis on pitta, surgery, and blood, this work best represents the transformational value of life. It is dais that this work was first redacted by Nagarjuna. This work, originally written in Sanskrit, is now available in English with Devanagari. Bhishagratnas translation is English and Sanskrit. P. V. Sharma has recently written a translation with both the Sanskrit/Devanagari and English that includes Dallanas commentary. Dallana has been regarded as the most influential commentator on Sushrutas work. Explanation Correct choices B d 21. Prozone phenomenon in precipitation reaction indicates a. False positive reaction b. False negative reaction c. due to excess antibodies d. Due to excess antigens e. Broken antibodies Ref: : AN 91 Quality:::: spotter 203. Which of the following are features of spinal shock f. Spasticity g. Urinary retention h. Areflexia i. Sensory level j. Increased DTRs Ref::clinical acumen Quality::::spotter thinker reader BATA Discussion Spinal shock(neuronal) is the initial state just after an acute insult causing an UMN lesion caused by the temporary depressant effect on the anterior horn cells. Characterized by paralysis,areflexia,flaccidity,the chracteristic hypertonia and increased relexes of cotticospinal lesion appear after few hrs-days. Explanation 6. Spasticity appears hrs day after spinal shock has passed in an UMN lesion. 7. Urinary retention is a feature of spinal cord disease. appears first in case of disease originating from the canal and spreading outwards and last in mass lesions compressing spinal cord from the outside. Its a feature of spinal shock. 8. Areflexia is a feature of spinal shock. 9. Sensory level is seen in case of corticospinal lesion. 10. Increased DTRs will be seen after the spinal shock has passed. Correct choices B C d 202. Diseases inherited with triple repeat sequences include a. Huntingtons chorea b. Alzheimers disease c. Spinocerebellar ataxia d. Amyotrophic lateral sclerosis e. Ataxia telangiectasia Ref:: Robbins 197,739,741,157 Quality::::spotter thinker reader BATA Discussion Harrison 2294 table gives explicit information about genetic defects in neurological disease. Robbins has enumerated three diseases having triple repeat sequences: Fragile X syndrome Huntington;s ds, Myotonic dystrophy Explanation A. Huntingtons chorea:AD : CAG triple repeats in gene encoding proein huntingtin B. Alzheimers disease:AD mutations presenilin,apolipoprotein E4,APP genen C. Spinocerebellar ataxia:expansion of trinucleotide repeats in ataxin gene D. Amyotrophic lateral sclerosis:AD mutation in Cu-Zn superoxide Dismutase SOD. 5. Ataxia telangiectasia AR mutation in ATM gene which causes triple repeat sequences and abnormal production of protein. Correct choices A c e 59. Tumor markers of hepatocellular carcinoma include a. CEA b. Des gamma carboxyprothrombin c. CA 19-9 d. Fucosylated alpha protein e. Alpha fetoprotien elevated in greater than 70% Ref:: HPIM 579, CMDT 689 http://www. intouchlive. com/consults/ccn9903b. htm Quality::::spotter thinker reader BATA Discussion Alpha fetoprotein levels raised in Cirrhosis Massive liver necrosis Chronic hepatitis hepatocellular carcinoma Normal pregnancy Fetal distress or death Fetal neural tube defects-enencephaly & spina bifida Gonadal germ cell tumours teratoblastoma, Levels above 1000 ng/ml HCC CEA (Carcino Embryonic Antigen) elevated in: malignancies of the gastrointestinal tract (pancreas, colon, rectum), lung, breast, prostatic and ovary. inflammation and heavy smoking. CA-125 normally found in adult female fallopian tube, endometrium and endocervix. CA-15 elevated breast and lung cancer. . CA-199 elevated in intra-abdominal carcinomas, adenocarcinomas of the lung, gastric, biliary and colonic neoplasms. Explanation a. serum CEA levels alone are not specific for hepatocellular carcinoma but are nonetheless raised. correct choice. b. Des gamma carboxyprothrombin, an abnormal typre of [rothrombin which correlates with h levels of AFP. c. CA 19-9 levels are elevated in HCC. D most of the patients with hepatocellular carcinoma have an elevated serum concentration of fucosylated alpha-fetoprotein. correct choice. e. Alpha-fetoprotein elevated in greater than 70% . true. Correct choices A bcde 67. Which of the following are causes of posterior mediastinal mass: A. Neuroenteric cyst B. Neurogenic cyst C. Anterior thoraxic meningocele D. Lymphoma E. Bronchogenic cyst Anterior mediastinum: Middle Mediastinum: Posterior mediastinum: Germ cell neoplasm Lymphoma: Morgagni hernia Pericardial cyst Thymic lesions: Thyroid (Retrosternal goiter) Foregut duplication cysts Castlemans disease Lymphangioma Lymphoma Bronchogenic cyst Bochdalek Hernia Extramedullary Hematopoiesis Ganglioneuroma Ganglioneuroblastoma Neuroblastoma Lateral thoracic meningocele Malignant tumor of nerve sheath origin Neurofibroma Paraganglioma Pheochromocytoma Schwannoma Explanation A. Neuroenteric cyst is present in the posterior mediastinum or paravertebral area. B. Neurogenic cyst is present in the posterior mediastinum C. Anterior thoracic meningocele is present in the posterior mediastinum D. Lymphoma is a tumour of the middle or anterior mediastinum E. Bronchogenic cyst is a tumour of the middle mediastinum. Correct choices Abc 213. Peripheral neuropathy is seen in all of the following except a. Tuberculosis b. Polyarteritis nodasa c. Diabetes mellitus d. SLE 89. Diabetes mellitus is associated with all of the following except: a. Neuropathy b. Encephalopathy c. Myopathy d. Myelitis e. Myelopathy Ref: CMDT 1191,HPIM 2481 Quality::::spotter thinker reader BATA Discussion Diabetic neuromuscular involvement may manifest as: A. Distal symmetric polyneuropathy B. Isolated peripheral neuropathy-mononeuropathy C. Mononeuritis multiplex D. Painful neuropathy 5. Autonomic neuropathy 6. Cranial neuropathypainful opthalmoplegia 7. Diabetic amyotrophy/proximal neuropathy/lumbosacral plexopathy 8. Ischemic myopathy of thigh muscles D e 127. In carbon monoxide toxicity a. There is left shift of oxygen dissociation curve b. Saturation of oxygen at 50% PaO2 is decreased c. Oxygen content of arterial blood is decreased d. Induces a state of metabolic acidosis e. Oxygen is used in treatment Ref: Ganong 17th 633 Quality::::spotter thinker reader BATA Discussion Explanation a. There is left shift of oxygen dissociation curve. COHb shifts the curve of the remaining HbO2 to left decreasing the amount of O2 released by the normal saturated Hb. b. Saturation of oxygen at 50% PaO2 is decreased. I think this choice should be saturation of Hb at given PO2 is decreased which is untrue because the curve shifts to the left. This increases the saturation of Hb at givenPO2 and even makes the available HbO2 useless for oxygenation because it wont release the O2. c. Carboxu Hb reduces oxygen transportation by Hb thus Oxygen content of arterial blood is decreased. correct. d. Induces a state of metabolic acidosis because of the hypoxia e. Ventilation with O2 is preferable to ventilation with fresh air since O2 hastens the dissociation of COHb. Hyperbaric O2 is useful. 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So both books are given for reference 212. All of the following statements regarding bioavailability of a drug are true except: A. It is the proportion (fraction) of unchanged drug that reaches the systemic circulation. B. Bioavailability of an orally administered drug can be calculated by comparing the Area Under Curve (0- ) after oral and intravenous (iv) administration. C. Low oral bioavailability always and necessarily mean poor absorption. D. Bioavailability can be determined from plasma concentration or urinary excretion data. Answer: C (Low oral bioavailability always and necessarily mean poor absorption) Ref: Katzung, 7th edn, 40; KDT 5th edn, 15 & 4th edn, 15 Figure 2.4 Quality: Reader Status: New QTDF: KDT Discussion Bioavailability of a drug is defined as the fraction of unchanged drug reaching the systemic circulation following administration by any route. Following intravenous route the bioavailablilty is 100 %. Oral Route is associated with low bioavailability due to the following reasons 1. The drug may be incompletely absorbed 2. The absorbed drug may under go first pass metabolism in intestinal wall/liver or may be excreted in bile IM/SC Route may be associated with a low bioavailability and that is due to 1. Local Binding Bio availability is determined by the Area under the Plasma Concentration-time Curve. Explanation A. It is the proportion (fraction) of unchanged drug that reaches the systemic circulation. B. Bioavailability of an orally administered drug can be calculated by comparing the Area Under Curve (0- ) after oral and intravenous (iv) administration. C. Low oral bioavailability always and necessarily does not mean poor absorption. It could be also due to first pass metabolism D. Bioavailability can be determined from plasma concentration or urinary excretion data. Comments A drug with low bioavailability will have a very high Oral Dose compared to its parenteral dose (eg Propanolol) Tips This is an area from which few problems may be asked 213. The extent to which ionisation of a drug takes place is dependent upon pKa of the drug and the pH of the solution in which the drug is dissolved. which of the following statements is not correct. A. pKa of a drug is the pH at which the drug is 50% ionized. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma. Answer: D (Phenobarbitonewith a pKa of 7.2 is largely ionized at acid pH and will be about 40% non-ionised in plasma) Ref: KDT 5th edn, 12 Figure 2.3 & 4th edn, 2 Pages 11,12 Fig 2.3; Harper 25th edn, 23 Figures 3.6, 3.7 Quality: Thinker, needs basic concepts Status: New QTDF: KDT, Harper Discussion pKa of a substance is the pH at which it is 50 % ionized. And small changes of pH near its pKa will not affect the ionization of Acidic as well as Basic Drugs. And of course the knowledge of pKa is needed in predicting the behaviour of various drugs in body fluids. Just because we know the pKa of Aspirin we are able to understand why it is selectively concentrated in the gastric mucosa at concentration much higher than that of the gastric lumen. Because we know the pKa of Phenobarbitone, we are able to Use Forced Alkaline diuresis for its excretion Explanation A. pKa of a drug is the pH at which the drug is 50% ionized. B. Small changes of pH near the pKa of a weak acidic drug will not affect its degree of ionisation. C. Knowledge of pKa of a drug is useful in predicting its behaviour in various body fluids. D. Phenobarbitone with a pKa of 7.2 is largely unionized at acid pH and is more ionised in Alkaline pH. Remember Forced Alkaline Diuresis for Phenobarbituric ACID !!!!) Comments This question can be solved easily if one knows the basic concepts of Acid, Base and pH Tips As already told, if one has strong correct concepts in Acid Base and Electrolyte Balance, about 5% of Questions can be attended with minimum fuss This question carries a chance of being wrongly interpreted and considering Answer 4 as correct. Be careful !!! Phenobarbitone is Phenobarbituic ACID and is not a Basic Drug !!! 214. Presence of food might be expected to interfere with drug absorption by slowing gastric emptying, or by altering the degree of ionisation of the drug in the stomach. Which of the following statements is not correct example: A. Absorption of digoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food enhances the absorption of hydrochlorthiazide. D. Anitimalarial drug halofantrine is more extensively absorbed if taken with food. Answer: C (Presence of food enhances the absorption of hydrochlorthiazide) Ref: KDT 5th edn, 372 (Phenytoin), 748 (Halofantriene) and 4th edn, 492(digoxin), 384(Phenytoin), 565(Thiazides), Halofantriene Park, Katsung ,Harrison 15th edn, Table 414-4; Goodman Gilman 9th edn, 957; CMDT 2003,1441 Quality: Thinker Status: New QTDF: ?? Discussion Presence of Food generally dilutes the drug and retards absorption. Certain drugs form complexes with certain constituents of the food. For example Tetracycline complexes with Calcium and more over food delays Gastric emptying. Thus most drugs are better absorbed if taken in empty stomach. But few drugs which are irritant are better given with food. Explanation A. Absorption of digoxin as well as digitoxin is delayed by the presence of food. B. Concurrent food intake may severely reduce the rate of absorption of phenytoin. C. Presence of food has no effect on the absorption of hydrochlorthiazide. D. Anitimalarial drug halofantrine is more extensively absorbed if taken with fatty food (Katsung). Comments A question for which one needs knowledge of Pharmacokinetics (often ignored) Tips Make a note of drugs that are increased with food (other than Halofantriene) 215. In post-operative intensive care unit, five patients developed post-operative wound infection on the same day. The best method to prevent cross infection occurring in other patients in the same ward is to: A. Give antibiotics to all other patients in the ward. B. Fumigate the ward. C. Disinfect the ward with sodium hypo chlorite. D. Practice proper hand washing. 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