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Early stages of depression e. Recovering from depression 8. Absence of an underlysing organic cause Explanation A. Haloperidol is antipsychotic. B. Sertraline is the anti-depressant drug and is most suited for our patient. C. Alprazolarn is an anxiolytic. D. Olanzapine is antipsychotic. Comments You can solve these type of questions by two ways. One is to diagnose correctly as soon as you read the question and then deciding on the drug of choice. Alternatively, look at the drug list. Recollect the conditions in which those drugs are used. Make a note of the salient features of those conditions. Compare and look out the condition for which the features in the given question fit. Tips Be thorough with the drugs affecting mental functions. You can get question about them in Pharmacology as well as in Psychiatry. 244. A 41-year-old married female presented with headache for the last six month. She had several consultations. All her investigations were found to be within normal limits. She still insists that there is something wrong in her head and seeks another consultation. The most likely diagnosis is: A. Phobia. B. Psychogenic headache. C. Hypochondriasis. D. Depression. Answer: C (Hypochondriasis) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 97 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion Hypochondriasis is defined as a persistent preoccupation with a fear of belief of having one or more serious disease(s), based on persons own interpretation of normal body function or a minor physical abnormality. The other important features are: 1. Complete physical examination and investigations do not show presence of any significant abnormality 2. 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Anything that increases a behaviourmakes it occur more frequently, makes it stronger, or makes it more likely to occuris termed a reinforcer. A person will perceive starting something good or ending something bad as something worth pursuing, and they will repeat the behaviours that seem to cause these consequences. These consequences will increase the behaviours that lead to them they are reinforcers. These are consequences the animal will work to attain, so they strengthen the behaviour. Anything that decreases a behaviour - makes it occur less frequently, makes it weaker, or makes it less likely to occuris termed a punisher. Often, an animal (or person) will perceive ending something good or starting something bad as something worth avoiding, and they will not repeat the behaviours that seem to cause these consequences. These consequences will decrease the behaviours that lead to them they are punishers. Reinforcement Punishment (behaviour increases) (behaviour decreases) Positive Positive Reinforcement: (something added) Something added increases Positive Punishment  behaviour Something added decreases behaviour Negative Negative Reinforcement Negative Punishment (something removed) Something removed Something removed increases behaviour decreases behaviour 246. A 15-year-old boy feels that the dirt has hung onto him whenever he passes through the dirty street. This repetitive thought causes much distress and anxiety. He knows that there is actually no such thing after he has cleaned once but he is not satisfied and is compelled to think so. This has led to social withdrawal. He spends much of his time thinking about the dirt and contamination. This has affected his studies also. The most likely diagnosis is: A. Obsessive compulsive disorder. B. Conduct disorder. C. Agoraphobia. D. Adjustment disorder. Answer: A (Obsessive compulsive disorder) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 88 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion An obsession is defined as: 1. An idea, impulse or image which intrudes into conscious awareness repeatedly and 2. Is recognised as ones own idea, impulse or image, but is ego-alien and 3. Is recognised as irrational and absurd (insight present) and the 4. Patient tries to resist against it but is unable to do and the 5. Failure to resist leads to marked distress A compulsion is defined as: 1. A form of behaviour which usually follows obsessions 2. It is aimed at either preventing or neutralising the distress or fear arising out if obsession 3. The behaviour is not realistic and is either irrational or excessive 4. Insight is present, so the patient realises the irrationality of compulsion 5. The behaviour is performed with a sense of subjective compulsion (urge or impulse to act) In India it is more in unmarried males. Explanation A. Obsessive compulsive disorder is the correct answer as the boys thoughts are repetitive and lead to distress and he knows that there is no such thing. B. Conduct disorder is a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. These behaviours include aggressive conduct that causes or threatens physical harm to other people or animals, non-aggressive conduct that causes property loss or damage, deceitfulness or theft, and serious violations of rules. The onset is before age 18. C. Agoraphobia: is an unexplained fear of open spaces, public spaces, crowded spaces and any other place from which there is no easy escape to a safe place. And a full blows panic attack may occur and the patient may become self-imprisoned at home. The self-imprisonment is due to fear of facing people and not because of dirt as happens in our boy. D. Adjustment disorders are maladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor. Comments If there was a choice Obsessive Thoughts, then that would be a more suitable answer as this boy does not have any compulsions. 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All of the following are features of hallucinations, except: A. It is independent of the will of the observer. B. Sensory organs are not involved. C. It is a vivid as that in a true sense perception. D. It occurs in the absence of perceptual stimulus. Answer: C (It is a vivid as that in a true sense perception) Ref: Kaplan and Sadocks Synopsis of Psychiatry, 284. Quality: Thinker Status: New Question QTDF: All books define hallucination !! Discussion Kaplan and Sadock defines hallucination as false sensory perception, not associated with real external stimulus. Whereas illusion is misperception or misinterpretation of real external stimulus Explanation A. It is independent of the will of the observer and this statement is true (though there is a rare type which is dependent. B. Sensory organs are not involved and this is a true statement. Sensory organs are involved only in illusion. Hallucination involves only Sensations. C. It is a vivid as that in a true sense perception. Remember that not all hallucinations are as vivid as in true sense perception. Only the hallucinations which occur in delirium tremens are vivid. D. It occurs in the absence of perceptual stimulus. And this is the very definition of hallucination. Comments Anyone who says that the answer is not C, kindly give your definition of illusion. Remember that sense organs and sensations are different terms. Sensations are involved in both hallucination and illusion whereas sense organs are involved in illusion only. Tips Make sure that you know about the various types of hallucinations. 238. Delirium tremens is characterised by confusion associated with: A. Autonomic hyperactivity and tremours. B. Features of intoxication due to alcohol. C. Sixth nerve palsy. D. Korsakof's psychosis. Answer: A (Autonomic hyperactivity and tremours) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, No 36 Quality: Reader Status: New QTDF: Ahuja Discussion Delirium tremens (DT) is the most severe alcohol withdrawal syndrome. It occurs usually within 2-4 days of complete or significant abstinence from heavy alcohol drinking in 5% of the patients, as compared to acute tremulousness which occurs in 34% of the patients. The course is short with recovery occurring within 3-7 days. This is an acute organic brain syndrome with the characteristic features of : a. Clouding of consciousness with disorientation in time and place. b. Poor attention span and distractibility. c. Visual and auditory hallucinations and illusion which are often vivid and frightening. Tactile hallucinations of insects crawling over body may occur. d. Marked autonomic disturbance with tachycardia, fever, sweating, hypertension and pupillary dilation. e. Psychomotor agitation and ataxia f. Insomnia, with a reversal of sleep-wake pattern. g. Dehydration with electrolyte imbalance. Explanation A. Autonomic hyperactivity and tremours are the features of delirium tremens. B. Features of intoxication due to alcohol will not be seen in delirium tremens. remember that delirium tremens occurs in conditions of No Alcohol and not in alcoholic intoxication where there are plenty of alcohol. C. Sixth nerve palsy is a feature of alcoholic intoxication. D. Korsakoff's psychosis occurs in alcoholic intoxication. Comments This question is easier to answer as choices B, C, D are concerned with alcoholic intoxication. Tips This question and the next one given here forms an example of the theme couple that you so often see in All India and AIIMS question. 239. An alcoholic is brought to the Emergency OPD with the complaint of irrelevant talking. He had stopped using alcohol three days back. On examination, he is found to be disoriented to time, place and person. He also has visual illusions and hallucinations. There is no history of head injury. The most likely diagnosis is: A. Dementia praecox. B. Delirium tremens. C. Schizophrenia. D. Korsakoffs psychosis. Answer: B (Delirium tremens) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 36 Quality: Reader Status: Repeat (from the same question paper !!!) QTDF: Ahuja Discussion Please go through the discussion on delirium tremens. You will find that all the features mentioned in the question are there as features of alcohol withdrawal and to add to the clue is the fact that the patient is a known alcoholic and he has stopped taking alcohol for the past 3 days. Explanation A. Dementia praecox is the old name of Schizophrenia. B. Delirium tremens is the correct answer as explained above. C. A patient of schizophrenia will not be disoriented to time place and person. D. Korsakoffs psychosis occurs after using alcohol and not after abstaining from alcohol. Comments Read the relevant chapters on alcoholic and other addictive substances with special emphasis on the toxicity as well as withdrawal symptoms. Tips Questions like these which are straight and easy are nowadays very rare. Though this is a simple question, I have to warn you that if you come across a simple looking question in AIIMS and All India Question Paper, please read it a couple of times more. The chances are that there is a trap there. 240. A male child of 15 years, with a mental age of 9 years has an IQ of: A. 50 B. 60 C. 70 D. 80 Answer: B (60) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 146 Quality: Spotter Status: Repeat QTDF: Ahuja Discussion IQ or Intelligence Quotient is the basis for the classification of mental retardation. 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All of the following are features of hallucinations, except: A. It is independent of the will of the observer. B. Sensory organs are not involved. C. It is a vivid as that in a true sense perception. D. It occurs in the absence of perceptual stimulus. Answer: C (It is a vivid as that in a true sense perception) Ref: Kaplan and Sadocks Synopsis of Psychiatry, 284. Quality: Thinker Status: New Question QTDF: All books define hallucination !! Discussion Kaplan and Sadock defines hallucination as false sensory perception, not associated with real external stimulus. Whereas illusion is misperception or misinterpretation of real external stimulus Explanation A. It is independent of the will of the observer and this statement is true (though there is a rare type which is dependent. B. Sensory organs are not involved and this is a true statement. Sensory organs are involved only in illusion. Hallucination involves only Sensations. C. It is a vivid as that in a true sense perception. Remember that not all hallucinations are as vivid as in true sense perception. Only the hallucinations which occur in delirium tremens are vivid. D. It occurs in the absence of perceptual stimulus. And this is the very definition of hallucination. Comments Anyone who says that the answer is not C, kindly give your definition of illusion. Remember that sense organs and sensations are different terms. Sensations are involved in both hallucination and illusion whereas sense organs are involved in illusion only. Tips Make sure that you know about the various types of hallucinations. 238. Delirium tremens is characterised by confusion associated with: A. Autonomic hyperactivity and tremous. B. Features of intoxication due to alcohol. C. Sixth nerve palsy. D. Korsakof's psychosis. Answer: A (Autonomic hyperactivity and tremours) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, No 36 Quality: Reader Status: New QTDF: Ahuja Discussion Delirium tremens (DT) is the most severe alcohol withdrawal syndrome. It occurs usually within 2-4 days of complete or significant abstinence from heavy alcohol drinking in 5% of the patients, as compared to acute tremulousness which occurs in 34% of the patients. The course is short with recovery occurring within 3-7 days. This is an acute organic brain syndrome with the characteristic features of : a. Clouding of consciousness with disorientation in time and place. b. Poor attention span and distractibility. c. Visual and auditory hallucinations and illusion which are often vivid and frightening. Tactile hallucinations of insects crawling over body may occur. d. Marked autonomic disturbance with tachycardia, fever, sweating, hypertension and pupillary dilation. e. Psychomotor agitation and ataxia f. Insomnia, with a reversal of sleep-wake pattern. g. Dehydration with electrolyte imbalance. Explanation A. Autonomic hyperactivity and tremours are the features of delirium tremens. B. Features of intoxication due to alcohol will not be seen in delirium tremens. remember that delirium tremens occurs in conditions of No Alcohol and not in alcoholic intoxication where there are plenty of alcohol. C. Sixth nerve palsy is a feature of alcoholic intoxication. D. Korsakoff's psychosis occurs in alcoholic intoxication. Comments This question is easier to answer as choices B, C, D are concerned with alcoholic intoxication. Tips This question and the next one given here forms an example of the theme couple that you so often see in All India and AIIMS question. 239. An alcoholic is brought to the Emergency OPD with the complaint of irrelevant talking. He had stopped using alcohol three days back. On examination, he is found to be disoriented to time, place and person. He also has visual illusions and hallucinations. There is no history of head injury. The most likely diagnosis is: A. Dementia praecox. B. Delirium tremens. C. Schizophrenia. D. Korsakoffs psychosis. Answer: B (Delirium tremens) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 36 Quality: Reader Status: Repeat (from the same question paper !!!) QTDF: Ahuja Discussion Please go through the discussion on delirium tremens. You will find that all the features mentioned in the question are there as features of alcohol withdrawal and to add to the clue is the fact that the patient is a known alcoholic and he has stopped taking alcohol for the past 3 days. Explanation A. Dementia praecox is the old name of Schizophrenia. B. Delirium tremens is the correct answer as explained above. C. A patient of schizophrenia will not be disoriented to time place and person. D. Korsakoffs psychosis occurs after using alcohol and not after abstaining from alcohol. Comments Read the relevant chapters on alcoholic and other addictive substances with special emphasis on the toxicity as well as withdrawal symptoms. Tips Questions like these which are straight and easy are nowadays very rare. Though this is a simple question, I have to warn you that if you come across a simple looking question in AIIMS and All India Question Paper, please read it a couple of times more. The chances are that there is a trap there. 240. A male child of 15 years, with a mental age of 9 years has an IQ of: A. 50 B. 60 C. 70 D. 80 Answer: B (60) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 146 Quality: Spotter Status: Repeat QTDF: Ahuja Discussion IQ or Intelligence Quotient is the basis for the classification of mental retardation. 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The fear or belief is not a delusion. Read this once more. You may get a question from this and if you guess, it may be wrong 4. Preoccupation with medical terms and syndromes is common. Repeated change of physicians is common Aetiology may be psychodynamic theory or it may be a symptom of depression. Symptoms consist of supportive psychotherapy or treatment of associated or underlying depression and/or anxiety. Explanation A. Phobia does not have headache for six months. B. A person with psychogenic headache will not insist that there is something wrong even after being told with all clinical and lab reports. C. Hypochondriasis is the correct diagnosis and the question lists the typical features. D. Depression is a vague answer and when as hypochondriasis is given as one of the choices, we go for the specific choice. Comments Somatisation disorder also presents like this, but in somatisation disorder, there are vague symptoms. Tips Somatoform disorders are a topic in Psychiatry where we can slip while answering MCQs if we dont read the question carefully. 245. Behaver therapy to change maladaptive behaviours using response as reinforcer uses the principles of : A. Classical conditioning. B. Moneling. C. Social learning. D. Operant conditioning. Answer: D (Operant conditioning) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 198 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion A type of conditioning developed by Skinner in which an experimenter waits for the target response (head scratching) to be conditioned to occur (emitted) spontaneously, immediately after which the organism is given a reinforcer reward; after this procedure is repeated many times, the frequency of emission of the targeted response will have significantly increased over its pre-experiment base rate. Explanation A. Classical conditioning: Learning that takes place when a conditioned stimulus is paired with an unconditioned stimulus. This situation resembles most closely the archetypic experiment from I. Pavlov in the 1920s, where he trained dogs to associate a tone with a food-reward. In such experiments, the subject initially shows weak or no response to a conditioned stimulus (CS) e.g. a tone, but a measurable unconditioned response (UR) e.g. saliva production to a unconditioned stimulus (US) e.g. food. In the course of the training, the CS is repeatedly presented together with the US; eventually the subject forms an association between the US and the CS. In a subsequent test-phase, the subject will show the conditioned response (CR) e.g. saliva production to the CS alone, if such an association has been established and memorised. Such Pavlovian conditioning is opposed to instrumental or operant conditioning, where producing a CR controls the US presentations. B. Moneling: I havent heard this word before Assuming this as a spelling mistake let us see a few words about modeling. Modeling, in learning theory, is the acquiring and learning of a new skill by observing and imitating that behaviour being performed by another individual. Modeling, in behaviour modification, is a treatment procedure whereby the therapist or another significant person presents (models) the target behaviour which the learner is to imitate and make part of his repertoire. C. Social learning: The social learning theory is the behaviour theory most relevant to criminology. Albert Bandura believed that aggression is learned through a process called behaviour modeling. He believed that individuals do not actually inherit violent tendencies, but they modeled them after three principles. (Attention, Retention and Motor Reproduction). Children learn to act aggressive when they model their behaviour after violent acts of adults, especially family members. For example, the boy who witness his father repeatedly strike his mother will more than likely become an abusive parent and husband. Albert Bandura argued that individuals, especially children, learn aggressive reponses from observing others, either personally or through the media and environment. He stated that many individuals believed that aggression will produce reinforcements. These reinforcements can formulate into reduction of tension, gaining financial rewards, or gaining the praise of others, or building self-esteem. D. Operant conditioning: It is a condition where producing a CR controls the US presentations. We use the term operant conditioning to describe one type of associative learning in which there is a contingency between the response and the presentation of the reinforcer. This situation resembles most closely the classic experiments from Skinner, where he trained rats and pigeons to press a lever in order to obtain a food reward (Skinner-Box, see figure). In such experiments, the subject is able to generate certain motor-output, (the response R, e.g. running around, cleaning, resting, pressing the lever). The experimentator choses a suited output (e.g. pressing the lever) to pair it with an unconditioned stimulus (US) e.g. a food reward. Often, a discriminative stimulus (SD) e.g. a light is present, when the R-US contingency is true. After a training period, the subject will show the conditioned response (CS) e.g. touching the trigger even in absence of the US, if the R-US association has been memorised. Such instrumental or operant conditioning is opposed to Pavlovian or classical conditioning, where producing a response has no effect on US presentations. Comments Operant conditioning procedures can be used to: 1. Increasing a behaviour a. Positive reinforcement b. Negative reinforcement c. Modeling 2. Decreasing a behaviour: a. Time out b. Punishment c. 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And a full blows panic attack may occur and the patient may become self imprisoned at home. The self imprisonment is due to fear of facing people and not because of dirt as happens in our boy D. Adjustment disorders are Maladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor. 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Comments The usual question in AIIMS and All India will not stop with this level. They will ask the degree of mental retardation. Fortunately, this year the question is too simple. Tips Take this as a cue and go through all those tables dealing with mild moderate, etc. Another area in your PG Preparation where you get tables with grading is Paediatrics. Pay special attention to the tables in Protein Energy Malnutrition. 241. All of the following are impulse control disorders, except: A. Pyromania. B. Trichotillomania. C. Kleptomania. D. Capgras syndrome. Answer: D (Capgras syndrome) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 81, 111 Quality: New Status: Reader QTDF: Ahuja Discussion Impulse control disorders are characterized by impulsive behaviour which the patient cannot resist or control. There may be a feeling of release of tension by doing the act and a feeling of guilt after the act is over. The treatment consists of behaviour therapy (e.g. aversion therapy) cognitive behaviour therapy, individual psychotherapy and occasionally pharmacotherapy (e.g. carbamazapine for intermittent explosive disorder, fluoxetine for trichotillomania. Explanation A. Pyromania is an impulse control disorder and is pathological fire setting. B. Trichotillomania is an impulse control disorder and is compulsive hair pulling. C. Kleptomania is an impulse control disorder and is pathological stealing. D. Capgras syndrome is not an impulse control disorder. Comments Capgras' syndrome is a syndrome that is closely related to delusional disorders and it is characterised by a delusional conviction that the other persons in the environment are not their real selves but their doubles. It is commonly seen in psychotic conditions with delusional symptomatology like paranoid schizophrenia (most frequently) delusional disorders and organic delusional disorder. The treatment is of the underlying disorder. There are four types: 1. Typical Capgras syndrome: Illusion des sosies' is a condition in which the person sees a familiar person as a stranger. 2. Illusion des fregoli is a condition in which the person sees a stranger as a familiar person. 3. Syndrome of subjective doublikes: The persons own self is perceived as being replaced by a double. 4. Intermetamorphosis: Here the patients misidentification is complete (including not only the external appearance as in the previous 3 types, but also the personality). Tips This is an easy question but the question will be tough if the 4th choice is changed to dipsomania (in diabetes) or erotomania or hypomania. 242. A 20- year-old man has presented with increased alcohol consumption and sexual indulgence, irritability, lack of sleep, and not feeling fatigued even on prolonged periods of activity. All these changes have been present for 3 weeks. The most likely diagnosis is: A. Alcohol dependence. B. Schizophrenia. C. Mania. D. Impulsive control disorder. Answer: C (Mania) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 65 Quality: Reader Status: Repeat QTDF: Ahuja Discussion Features of Manic Episodes (at least for 1 week) include: 1. Elevated, expansive or irritable mood: Stages Mood Euphoria Mild Elevation Psychological Hypomania Stage I of Mood Well being Elation Moderate Increased Classical Mania Stage II Elevation of psychomotor Mood Mood Exaltation Severe Elevation Intense Elation Severe Mania Stage III of Mood with Delusion of Grandeur Ecstasy Very Severe Intense sense Delirious or Stage IV Elevation of of Rapture Stuporous Mania Mood 2. Psychomotor activity a. Overactiveness and restlessness b. Activity is goal oriented c. Patient is on the go 3. Speech and thought a. More talkative, describes thoughts racing in mind, develops pressure of speech, uses playful language with puning, rhyming, joking and teasing b. Flight of ideas 4. Goal-directed activity: a. Ability to function is better. b. Many artists and writers contribute significantly 5. Other features a. Sleep reduced b. Insight absent c. Mood incongruent psychotics features may be present 6. Absence of underlying organic cause Explanation A. Other than that he takes alcohol, no other feature supports alcohol dependence. B. Schizophrenia rarely presents like this. C. Mania is the correct diagnosis for this patient. We can see that all the features that are seen in this patient are the ones seen in mania. D. Impulsive control disorder does not present like this. Please look at the other question for impulse control disorders. Comments If you cannot match the answer at the first attempt, try exclusion of the other choices. But keep in mind that there are negative marks in these exams !! Tips Mania and depression along with schizophrenia, delusion, hallucination, drug dependence are the common topics from which you will get questions and these questions will be answered by the majority and if you leave a question in these topics, you may be left out in the race. 243. A 50-year-old man has presented with pain in back, lack of interest in recreational activities. Low mood, lethargy, decreased sleep and appetite for two months. There was no history suggestive of delusions or hallucination. He did not suffer from any chronic medical illness. There was no family history of psychiatric illness. Routine investigations including haemogram, renal function tests, liver function tests, electrocardiogram did not reveal any abnormality. This patient should be treated with: A. Haloparidol. B. Sertraline. C. Alprazolarn. D. Olanzapine. Answer: B (Sertraline) Ref: A Short Textbook of Psychiatry by Ahuja 4 th edn, 66, 71 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion Features of Depressive Episodes (at least for 2 weeks) include: 1. Depressed mood a. Pervasive sadness b. Persistent sadness c. Social withdrawal, decreased ability to function in occupational and interpersonal areas and decreased involvement in previously pleasurable activities 2. Depressive ideation a. Hopelessness b. Helplessness c. Worthlessness d. Difficulty in thinking, difficulty in concentration, indecisiveness, slowed thinking, subjective poor memory, lack of initiative and energy and delusion of nihilism 3. Psychomotor activity a. In younger patientsslowed thinking and activity, decreased energy, monotonous voice, depressive stupor b. In older patientsagitation, marked anxiety, restlessness, inability to sit still, hand wriggling, picking at body parts and subjective feeling of unease 4. Physical symptoms a. Heaviness of head, vague bodyaches b. Hypochondral features 5. Biological functions a. Insomnia, loss of appetite and weight and loss of sexual desire and sometimes hyperphagia and weight gain b. Presence of somatic symptoms indicate a severe disease 6. Psychotic features: a. Delusion, hallucinations, grossly inappropriate behaviour or stupor. b. They can be mood congruent (Nihilistic delusions, delusions of guilt,delusions of poverty, stupor, etc) or mood incongruent (Delusions of control) 7. Suicidal risks are more in: a. Presence of marked helplessness b. 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h]hhYh](h ,@ l UX.XX|X ,@ l ,@ l ,@ l ,@ l hXXXX,@ l ,@ l ,@ l :,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ?,@ l hhhhBhh h,h ,@ l %XQX#X$X ,@ l ,@ l ,@ l ,@ l *h XXXX,@ l ,@ l ,@ l 5,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l h,@ l ,@ l 2XX\XX ,@ l g,@ l ,@ l ,@ l ,@ l mhXXXX,@ l ,@ l ,@ l 6,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l h h ,@ l 0,@ l hChR,@ l +,@ l B,@ l W,@ l u ,@ l h$XXXX,@ l ",@ l ,@ l 5,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l \h,@ l h),@ l ,@ l X,@ l S,@ l ,@ l ,@ l +,@ l h  h,@ l Yh%XXX#X,@ l ,@ l ,@ l (,@ l ,@ l $,@ l ,@ l ,@ l ,@ l ^X.X-XXX ,@ l ,@ l ,@ l a,@ l UhXXXX,@ l ,@ l ,@ l ?hhQ,@ l hh,@ l h9,@ l h) ,@ l #,@ l ,@ l h h 2,@ l ' ,@ l NXpX?XX ,@ l s,@ l ,@ l C,@ l \hX XXX,@ l ,@ l ,@ l b,@ l ,@ l ',@ l ,@ l ,@ l ,@ l XMX,XVX ,@ l C,@ l ,@ l 0,@ l I,@ l ,@ l ,@ l ,@ l ,@ l ,@ l hXXXX,@ l ,@ l ,@ l ,@ l ,@ l *,@ l ,@ l ,@ l ,@ l X7X6XJX ,@ l ,@ l ,@ l 4,@ l ,@ l d,@ l X XXX,@ l ,@ l ,@ l 0,@ l ,@ l %,@ l ,@ l Gh]h/h+h ,@ l ,@ l ,@ l !,@ l h%h h,@ l -,@ l ,@ l Ph X X X X,@ l ,@ l ,@ l _,@ l ,@ l +,@ l ,@ l 9,@ l ,@ l H,@ l ,@ l Mhhh:h,@ l U,@ l ,@ l hXXXX,@ l ,@ l ,@ l H,@ l ,@ l *,@ l ,@ l k,@ l ,@ l ,@ l ,@ l 9hh,@ l ,@ l ,@ l ,@ l #,@ l hhhhhh,@ l ahP,@ l ,@ l ,@ l ,@ l ,@ l ,@ l C,@ l ,@ l ,@ l H,@ l ,@ l :,@ l ,@ l h],@ l ,@ l :,@ l ,@ l 6,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l Hh1XX,X+X,@ l +,@ l ,@ l 6,@ l ,@ l %,@ l ,@ l ,@ l ,@ l ,@ l ,@ l x,@ l ,@ l c,@ l dh[,@ l ,@ l ,@ l ,@ l 8,@ l ,@ l #,@ l ,@ l h4h$h4hh2h"hghhkhbh^h ,@ l tX%X(XIX ,@ l y,@ l hh,@ l ,@ l ,@ l _hXXXX,@ l ,@ l ,@ l @,@ l ,@ l %,@ l ,@ l a,@ l ,@ l ,@ l ,@ l 3,@ l (h/h.h,@ l ,@ l ,@ l FhX,@ l X%X,@ l ,@ l ,@ l K,@ l ,@ l %,@ l ,@ l Yh0h,h6,@ l ;hlh?hQh ,@ l RX0,@ l .XGX ,@ l c,@ l ,@ l P,@ l ,@ l fh,@ l ,@ l ,@ l ,@ l 8,@ l ,@ l $,@ l ,@ l 0,@ l L,@ l ,@ l ,@ l ,@ l =,@ l ,@ l ,@ l ,@ l 6,@ l ,@ l F,@ l ,@ l Q,@ l ,@ l $,@ l ,@ l ,@ l ,@ l ,@ l ,@ l O,@ l ,@ l V,@ l ,@ l ,@ l Sh7XDXDXDX,@ l 6,@ l ,@ l 8,@ l ,@ l $,@ l ,@ l Chhh1hahOhph ,@ l 1XDXDXDX ,@ l `,@ l ,@ l +,@ l p,@ l ,@ l ,@ l Bh,@ l ,@ l ,@ l ,@ l 8,@ l ,@ l $,@ l ,@ l ,@ l h"6%h"A&hU,' ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l lhXXXX,@ l ,@ l ,@ l U,@ l ,@ l $,@ l ,@ l x,@ l ,@ l 0X-XPXBXh=hh ,@ l l,@ l ,@ l ,@ l ,@ l ,@ l ;hG,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ",@ l ,@ l X,@ l hhhh ,@ l ,@ l ,@ l ,@ l ,@ l n,@ l 5hG,@ l ,@ l !,@ l ,@ l u,@ l 3,@ l ,@ l 1,@ l ,@ l ,@ l hhh h#hh,@ l hhhhhhh ,@ l ,@ l ,@ l 6,@ l ,@ l t,@ l h>X@X@XBX,@ l ?,@ l ,@ l u,@ l ,@ l M,@ l ,@ l v,@ l ,@ l XMXXXZX ,@ l *,@ l ,@ l ,@ l ,@ l h-X-X,X-X,@ l ,,@ l ,@ l 8,@ l ,@ l %,@ l ,@ l ,@ l ,@ l ,@ l ,@ l 8,@ l ,@ l W,@ l ,@ l ,@ l 8hNXDX8XSX,@ l M,@ l ,@ l g,@ l ,@ l !,@ l ,@ l rhschnxhl ,@ l jXeXLXnX ,@ l ,@ l ,@ l ,@ l Zh,@ l ,@ l 8,@ l ,@ l 8,@ l ,@ l o,@ l ,@ l ,@ l ,@ l +,@ l %h|Yba3h.h-57Bh,@ l hh h ,@ l ,@ l ,@ l M,@ l ,@ l ,@ l Mh,@ l ,@ l ,@ l ,@ l 4,@ l ,@ l $,@ l ,@ l 2,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l Mh9X XXX,@ l ,@ l ,@ l 8,@ l ,@ l !,@ l ,@ l !,@ l ,@ l ,@ l ,@ l WX>X>X5X ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l &hh!h!hh&h#h%h'h,@ l ,@ l ,@ l ?h X X X X,@ l ,@ l ,@ l ,@ l ,@ l %,@ l W,@ l ,@ l &,@ l ,@ l ,@ l ,@ l ,@ l ,@ l +,@ l ,@ l i,@ l ,@ l 1hXXXX,@ l ,@ l ,@ l o,@ l ,@ l &,@ l ,@ l ,@ l ,@ l .X;X X2X ,@ l e,@ l ,@ l ',@ l l,@ l ,@ l ,@ l ,@ l _,@ l ,@ l (,@ l ,@ l ,@ l ,@ l S,@ l ,@ l 1,@ l ,@ l ,@ l ,@ l ,@ l hP,@ l ,@ l ,@ l ,@ l `,@ l ,@ l J,@ l ,@ l ,@ l ,@ l ,@ l 9Xm,@ l ,@ l ,@ l ,@ l ,@ l ,@ l h,@ l ,@ l -,@ l ,@ l x,@ l ,@ l 4,@ l ,@ l ,@ l ,@ l ,@ l ,@ l P,@ l ,@ l ,@ l 0hJ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l 4,@ l ,@ l 9,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ;,@ l ,@ l ,@ l ,@ l ,@ l \,@ l ,@ l 0,@ l ,@ l _,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l KhX XXX,@ l ,@ l ,@ l L,@ l ,@ l A,@ l ,@ l ,@ l ,@ l ,@ l (XX$X$X ,@ l ,@ l ,@ l N,@ l 9hXXXX ,@ l X,@ l 4,@ l ,@ l <,@ l ,@ l ,@ l 5,@ l ,@ l pX@X0X2X ,@ l o,@ l ,@ l ,@ l Uh3XX X<X,@ l ,@ l ,@ l ^,@ l ,@ l *,@ l ,@ l ,@ l hh hhU,@ l )h&hhY,@ l hhhhT,@ l &h&h ,@ l DXXeXMX ,@ l ,@ l ,@ l ,@ l ]h X XXX,@ l ,@ l ,@ l 9,@ l ,@ l +,@ l ,@ l /,@ l #,@ l >,@ l ,@ l ;,@ l ,@ l ,@ l ,@ l XXXX ,@ l -,@ l ,@ l ,@ l ah XXX X,@ l ,@ l ,@ l ],@ l ,@ l ),@ l ,@ l 9,@ l ,@ l ,@ l ,@ l (,@ l x,@ l v,@ l ,@ l ,@ l =,@ l [ho,@ l ,@ l ,@ l ,@ l ,@ l ,@ l _,@ l ,@ l ,@ l ,@ l ,@ l ,@ l _,@ l ,@ l ,@ l Oh,@ l ,@ l 1,@ l ,@ l %,@ l ,@ l ,@ l ,@ l ,@ l mhhjhh ,@ l N,@ l ,@ l 4,@ l ,@ l ,@ l h!XXX+X,@ l ,@ l ,@ l v,@ l ,@ l &,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l Uh,@ l ,@ l ,@ l ,@ l I,@ l ,@ l ',@ l ,@ l ,@ l ,@ l ,@ l ,@ l !,@ l ,@ l +,@ l &,@ l ,@ l b,@ l X"X(X-X,@ l ',@ l ,@ l H,@ l ,@ l 4,@ l ,@ l ,@ l ,@ l ,@ l ,@ l ,@ l hh}h,@ l ,@ l [hX"XXX,@ l ,@ l ,@ l 2,@ l ,@ l #,@ l ,@ l ),@ l ,@ l ,@ l ,@ l ,@ l %,@ l ,@ l ,@ l <hXXXX,@ l ,@ l ,@ l #,@ l ,@ l *,@ l ,@ l ,@ l H,@ l 6,@ l ,@ l ,@ l /X.X6X5X ,@ l ,@ l ,@ l ,@ l ,@ l h"X(X-XX,@ l ,,@ l ,@ l (,@ l ,@ l &,@ l ,@ l Mhhh>1WhhD1,@ l #,@ l )0,@ l ,@ l ,@ l ,@ l ,@ l S,@ l %hh&h,@ l phhe,@ l @,@ l :,@ l ,@ l wh+X$XXX,@ l ,@ l ,@ l &,@ l ,@ l &,@ l ,@ l 1,@ l hCh&,@ l hCh h ,@ l !hh+h,@ l h ,@ l ,@ l ,@ l ,@ l ,@ l 1,@ l !h$h#hh%h+h ,@ l lh X#XXX,@ l ,@ l ,@ l &,@ l ,@ l &,@ l ,@ l {,@ l hh h ,@ l ,@ l ,@ l ,@ l )h!h4h,@ l 3,@ l ,@ l 3X"XXX,@ l !,@ l ,@ l >,@ l ,@ l /,@ l ,@ l ,@ l ,@ l v,@ l 6,@ l ,@ l ,@ l XSXOXsX ,@ l (,@ l ,@ l ,@ l ,@ l ,@ l h.XXXX ,@ l X,@ l ',@ l ,@ l &,@ l ,@ l ,@ l ,@ l jXXaXSX ,@ l u,@ l ,@ l G,@ l ,@ l v,@ l XXXX,@ l ,@ l ,@ l K,@ l ,@ l $,@ l ,@ l {,@ l ,@ l `XYXXX ,@ l hhhhh,@ l Z,@ l mh&XX(X0X,@ l %,@ l ,@ l P,@ l ,@ l .,@ l ,@ l *,@ l g,@ l h,@ l ,@ l -,@ l ,@ l 7X6XkXX ,@ l ,@ l ,@ l ,@ l UhXFXXX,@ l D,@ l ,@ l D,@ l ,@ l ,@ l ,@ l RXFXCX>X ,@ l ,@ l ,@ l ,@ l 3hXXXX,@ l ,@ l XX,@ l ,@ l ,@ l M,@ l ,@ l B,@ l bhzh9-81#h ,@ l ,@ l ,@ l K,@ l ,@ l ,@ l ,@ l ,@ l X5X7XX,@ l 6,@ l ,@ l ],@ l ,@ l *,@ l ,@ l hhh ,@ l XUXSX/X ,@ l .,@ l GhJ,@ l <h^,@ l M,@ l F,@ l VhF,@ l ,@ l ,@ l ,@ l ,@ l ,@ l @( -5 R -[ 0x @ @  @  & .@ $ . +@: "V (l   ,@      (* @D X j y   % @ @   "  #! $8 @O )] x    + @ %  " ( 7 &D -] )z ,  0 $    * *>CcC,cC, c+C, c:#,CWcC,cC,c&C,1 cC,@BcC,@BcC,'Cb @B, C@B, CcC,cC,wcC,.caD3CXca: CXcaN CX caD CX)ca0CXecc, C@BcC,@BcC,C0@@,CC@B, C@B,!Cs cc, cBC@ cc, c c@ Ccc,Ccc, Ccc,Ccc, Cbcc, Ccc, c1C@ CCcC,C c c,c@ Cl cc, c@ CCc C,cC,c C, Cc C,5cC,GcC,CChCCC 52. 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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All of the following are features of hallucinations, except: A. It is independent of the will of the observer. B. Sensory organs are not involved. C. It is a vivid as that in a true sense perception. D. It occurs in the absence of perceptual stimulus. Answer: C (It is a vivid as that in a true sense perception) Ref: Kaplan and Sadocks Synopsis of Psychiatry, 284. Quality: Thinker Status: New Question QTDF: All books define Hallucination !! Discussion Kaplan and Sadock defines Hallucination as false sensory perception, not associated with real external stimulus. Where as Illusion is misperception or misinterpretation of real external stimulus Explanation A. It is independent of the will of the observer and this statement is true. (though there is a rare type which is dependent L B. Sensory organs are not involved and this is a true statement. Sensory organs are involved only in Illusion. Hallucination involves only SENSATIONS C. It is a vivid as that in a true sense perception. Remember that not all hallucinations are as vivid as in true sense percetion. Only the only the hallucinations which occur in Delirium tremens are vivid D. It occurs in the absence of perceptual stimulus. And this is the very definition of Hallucination Comments Any one who says that the answer is not 3, kindly give your definition of Illusion Remember that SENSE ORGANS and SENSATIONS are different terms. Sensations are involved in both Hallucination and Illusion where as SENSE ORGANS ARE INVOLVED IN ILLUSION only Tips Make sure that you know about the various types of Hallucinations 238. Delirium tremens is characterized by confusion associated with: A. Autonomic hyperactivity and tremors. B. Features of intoxication due to alcohol. C. Sixth nerve palsy. D. Korsakoff psychosis. Answer: A (Autonomic hyperactivity and tremors) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, No 36 Quality: Reader Status: New QTDF: Ahuja Discussion Delirium Tremens (DT) is the most severe alcohol withdrawal syndrome. It occurs usually within 2-4days of complete or significant abstinence from heavy alcohol drinking in 5 % of the patients, as compared to acute tremulousness which occurs in 34 % of the patients. The course is short with recovery occurring within 3 - 7 days. This is an acute organic brain syndrome with the characteristic features of a. Clouding of consciousness with disorientation in time and place b. Poor attention span and distractibility c. Visual and Auditory hallucinations and illusion which are often vivid and frightening. Tactile hallucinations of insects crawling over body may occur d. Marked autonomic disturbance with tachycardia, fever, sweating, hypertension and pupillary dilation. e. Psychomotor agitation and ataxia f. Insomnia, with a reversal of sleep - wake pattern. g. Dehydration with electrolyte imbalance Explanation A. Autonomic hyperactivity and tremors are the features of Delirium Tremens. B. Features of intoxication due to alcohol will not be seen in Delirium tremens. Remember that Delirium tremens occurs in conditions of No Alcohol and not in Alcoholic Intoxication where there are plenty of Alcohol. C. Sixth nerve palsy is a feature of Alcoholic Intoxication. D. Korsakoff psychosis occurs in Alcoholic Intoxication. Comments This question is easier to answer as choices 2,3,4 are concerned with Alcoholic Intoxication Tips This question and the next one given here forms an example of the theme couple that you so often see in All India and AIIMS question 239. An alcoholic is brought to the Emergency OPD with the complaint of irrelevant talking. He had stopped using alcohol three days back. On examination, he is found to be disoriented to time, place and person. He also has visual illusions and hallucinations. There is no history of head injury. The most likely diagnosis is: A. Dementia praecox. B. Delirium tremens. C. Schizophrenia. D. Korsakoffs psychosis. Answer: B (Delirium tremens) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 36 Quality: Reader Status: Repeat (from the same question paper !!!) QTDF: Ahuja Discussion Please go through the Discussion on Delirium Tremens. You will find that all the features mentioned in the Question are there as features of Alcohol Withdrawal and to add to the clue is the fact that the patient is an known alcoholic and he has stopped taking alcohol for the past 3 days Explanation A. Dementia praecox is the old name of Schizophrenia. B. Delirium tremens is the correct answer as explained above. C. A patient of Schizophrenia will not be disoriented to time place and person. D. Korsakoffs psychosis occurs after USING ALCOHOL and not after abstaining from Alcohol. Comments Read the relevant chapters on Alcoholic and other Addictive substances with special emphasis on the Toxicity as well as Withdrawal Symptoms Tips Questions like these which are straight and easy are nowadays very rare. Though this is a simple question, I have to warn you that if you come across a simple looking question in AIIMS and All India Question Paper, please read it a couple of times more. The chances are that there is a trap there 240. A male child of 15 years, with a mental age of 9 years has an IQ of: A. 50 B. 60 C. 70 D. 80 Answer: B (60) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 146 Quality: Spotter Status: Repeat QTDF: Ahuja Discussion IQ or Intelligence Quotient is the basis for the classification of Mental Retardation IQ is equal to Mental Age ie MA divided by Chronological Age ie CA multiplied by 100 ie IQ = MA/Cax100 B. 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Comments The usual question in AIIMS and All India will not stop with this level. They will ask the degree of Mental Retardation. Fortunately, this year the question is too simple Tips Take this as a cue and go through all those tables dealing with Mild Moderate etc. Another area in your PG Preparation where you get tables with grading is Paediatrics. Pay special attention to the tables in Protein Energy Malnutrition 241. All of the following are impulse control disorders except; A. Pyromania. B. Trichotillomania. C. Kleptomania. D. Capgras sydrome. Answer: D (Capgras sydrome) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 81, 111 Quality: New Status: Reader QTDF: Ahuja Discussion Impulse control disorders are characterized by impulsive behaviour which the patient cannot resist or control. There may be a feeling of release of tension by doing the act and a feeling of guilt after the act is over. The treatment consists of Behaviour therapy (eg aversion therapy)cognitive behaviour therapy, individual psychotherapy and occasionally pharmacotherapy (eg Carbamazapine for Intermittent Explosive disorder , fluoxetine for trichotillomania. Explanation A. Pyromania is an Impulse control disorder and is Pathological Fire setting. B. Trichotillomania is an Impulse control disorder and is compulsive hair pulling. C. Kleptomania is an Impulse control disorder and is pathological stealing. D. Capgras sydrome is not an impulse control disorder. Comments Capgras Syndrome is a syndrome that is closely related to delusional disorders and it is characterized by a delusional conviction that the other persons in the environment are not their real selves but heir doubles. It is commonly seen in psychotic conditions with delusional symptomatology like Paranoid Schizophrenia (most frequently) Delusional Disorders and Organic Delusional disorder. The treatment is of the underlying disorder There are 4 types 1. Typical Capgras Syndrome : Illusion des sosies is a condition in which the person sees a familiar person as a stranger. 2. Illusion des Fregoli is a condition in which the person sees a stranger as a familiar person. 3. Syndrome of Subjective doublkes : The persons own self is perceived as being replaced by a double 4. Intermetamorphosis : Here the patients mesidentification is complete ( including not only the external appearance as in the previous 3 types, but also the personality) Tips This is a easy question but the question will be tough if the 4th choice is changed to Dipsomania (in Diabetes) or Erotomania or hypomania 242. A 20- year-old man has presented with increased alcohol consumption and sexual indulgence, irritability, lack of sleep, and not feeling fatigued even on prolonged periods of activity. All these changes have been present for 3 weeks. The most likely diagnosis is: A. Alcohol dependence. B. Schizophrenia. C. Mania. D. Impulsive control disorder. Answer: C (Mania) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 65 Quality: Reader Status: Repeat QTDF: Ahuja Discussion Features of Manic Episodes (at least for 1 week) include 1. Elevated, Expansive or Irritable Mood Stages Mood Euphoria Mild Elevation Psychological Hypomania Stage I of Mood Well being Elation Moderate Increased Classical Mania Stage II Elevation of psychomotor Mood Mood Exaltation Severe Elevation Intense Elation Severe Mania Stage III of Mood with Delusion of Grandeur Ecstasy Very Severe Intense sense Delirious or Stage IV Elevation of of Rapture Stuporous Mania Mood 2. Psychomotor Activity a. Overactiveness and Restlessness b. Activity is Goal Oriented c. Patient is on the go 3. Speech and thought a. More talkative, Describes thoughts racing in Mind, develops pressure of speech, uses playful language with puning, rhyming, joking and teasing b. Flight of Ideas 4. Goal directed Activity a. Ability to function is better. b. Many artists and writers contribute significantly 5. Other features a. Sleep reduced b. Insight Absent c. Mood Incongruent psychotics features may be present 6. Absence of Underlying Organic Cause Explanation A. Other than that he takes Alcohol, no other feature supports Alcohol dependence. B. Schizophrenia rarely presents like this. C. Mania is the correct diagnosis for this patient. We can see that all the features that are seen in this patient are the ones seen in Mania D. Impulsive control disorder does not present like this. Please look at the other question for Impulse control disorders Comments If you cannot match the answer at the first attempt, try exclusion of the other choices. But keep in mind that there are negative marks in these exams !! Tips Mania and Depression along with Schizophrenia, Delusion, Hallucination, Drug dependence are the common topics from which you will get questions and these question will be answered by the majority and if you leave a question in these topics, you may be left out in the race 243. A 50-year-old man has presented with pain in back, lack of interest in recreational activities. Low mood, lethargy, decreased sleep and appetite for two months. There was no history suggestive of delusions or hallucination. He did not suffer from any chronic medical illness. There was no family history of psychiatric illness. Routine investigations including haemogram, renal function tests, liver function tests, electrocardiogram did not reveal any abnormality. This patient should be treated with: A. Haloparidol. B. Sertraline. C. Alprazolarn. D. Olanzapine. Answer: B (Sertraline) Ref: A Short Textbook of Psychiatry by Ahuja 4 th edn, 66, 71 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion Features of Depressive Episodes (at least for 2 weeks) include 1. Depressed Mood a. Pervasive Sadness b. Persistent Sadness c. Social Withdrawal, Decreased Ability to Function in Occupational and Interpersonal Areas and Decreased Involvement in Previously pleasurable activities 2. Depressive Ideation a. Hopelessness b. Helplessness c. Worthlessness d. Difficulty in thinking, difficulty in Concentration, Indecisiveness, Slowed thinking, subjective poor memory, lack of Initiative and Energy and Delusion of Nihilism 3. Psychomotor Activity a. In younger patients - Slowed thinking and activity, decreased energy, monotonous voice, Depressive stupor b. In older patients Agitation, marked anxiety, restlessness, inability to sit still, hand wriggling, picking at body parts and subjective feeling of unease 4. Physical Symptoms a. Heaviness of head, Vague body aches b. Hypochondral features 5. Biological Functions a. Insomnia, Loss of Appetite and Weight and loss of Sexual Desire and sometimes Hyperphagia and weight gain b. Presence of Somatic symptoms indicate a severe disease 6. Psychotic Features a. Delusion, hallucinations, grossly in appropriate behaviour or stupor. b. They can be mood congruent (Nihilistic delusions, Delusions of guilt, Delusions of poverty, stupor etc) or mood incongruent (Delusions of control) 7. Suicidal Risks are more in a. Presence of marked helplessness b. Males ; Aged >40, unmarried, divorced or widowed c. 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The fear or belief is NOT a delusion. Read this once more. You may get a question from this and if you guess, it may be wrong 4. Preoccupation with Medical Terms and Syndromes is common. Repeated change of Physicians is common Etiology may be Psychodynamic theory or it may be a symptom of depression. Symptoms consist of Supportive psychotherapy or treatment of associated or underlying depression an/or anxiety Explanation A. Phobia does not have headache for six months B. A person with psychogenic headache will not insist that there is something wrong even after being told with all clinical and lab reports C. Hypochondriasis is the correct diagnosis and the question lists the typical features. D. Depression is a vague answer and when as Hypochondriasis is given as one of the choices, we go for the specific choice. Comments Somatization disorder also presents like this, but in Somatization disorder, there are vague symptoms Tips Somatoform disorders are a topic in Psychiatry where we can slip while answering MCQs if we dont read the question carefully. 245. Behaver therapy to change maladaptive behaviors using response as reinforcer uses the principles of : A. Classical conditioning B. Moneling. C. Social learning. D. Operant conditioning. Answer: D (Operant conditioning) Ref: A Short Textbook of Psychiatry by Ahuja 4th edn, 198 Quality: Thinker Status: Repeat QTDF: Ahuja Discussion A type of conditioning developed by Skinner in which an experimenter waits for the target response (head scratching) to be conditioned to occur (emitted) spontaneously, immediately after which the organism is given a reinforcer reward; after this procedure is repeated many times, the frequency of emission of the targeted response will have significantly increased over its pre-experiment base rate. Explanation A. Classical conditioning : Learning that takes place when a conditioned stimulus is paired with an unconditioned stimulus. This situation resembles most closely the archetypic experiment from I. Pavlov in the 1920s, where he trained dogs to associate a tone with a food-reward. In such experiments, the subject initially shows weak or no response to a conditioned stimulus (CS, e.g. a tone), but a measurable unconditioned response (UR, e.g. saliva production) to a unconditioned stimulus (US, e.g. food). In the course of the training, the CS is repeatedly presented together with the US; eventually the subject forms an association between the US and the CS. In a subsequent test-phase, the subject will show the conditioned response (CR, e.g. saliva production) to the CS alone, if such an association has been established and memorized. Such Pavlovian conditioning is opposed to instrumental or operant conditioning, where producing a CR controls the US presentations. B. Moneling. I havent heard this word before; Assuming this as a spelling mistake let us see a few words about MODELING. Modeling, In learning theory, is the acquiring and learning of a new skill by observing and imitating that behaviour being performed by another individual. Modeling in behaviour modification, is a treatment procedure whereby the therapist or another significant person presents (models) the target behaviour which the learner is to imitate and make part of his repertoire. C. Social learning The social learning theory is the behavior theory most relevant to criminology. Albert Bandura believed that aggression is learned through a process called behavior modeling. He believed that individuals do not actually inherit violent tendencies, but they modeled them after three principles. (Attention, Retention and Motor Reproduction). Children learn to act aggressive when they model their behavior after violent acts of adults, especially family members. For example, the boy who witness his father repeatedly strike his mother will more than likely become an abusive parent and husband. Albert Bandura argued that individuals, especially children learn aggressive reponses from observing others, either personally or through the media and environment. He stated that many individuals believed that aggression will produce reinforcements. These reinforcements can formulate into reduction of tension, gaining financial rewards, or gaining the praise of others, or building self-esteem. D. Operant conditioning : is a condition where producing a CR controls the US presentations. We use the term operant conditioning to describe one type of associative learning in which there is a contingency between the response and the presentation of the reinforcer. This situation resembles most closely the classic experiments from Skinner, where he trained rats and pigeons to press a lever in order to obtain a food reward (Skinner-Box, see figure). In such experiments, the subject is able to generate certain motor-output, (the response R, e.g. running around, cleaning, resting, pressing the lever). The experimentator choses a suited output (e.g. pressing the lever) to pair it with an unconditioned stimulus (US, e.g. a food reward). Often a discriminative stimulus (SD, e.g. a light) is present, when the R-US contingency is true. After a training period, the subject will show the conditioned response (CS, e.g. touching the trigger) even in absence of the US, if the R-US association has been memorized. Such instrumental or operant conditioning is opposed to Pavlovian or classical conditioning, where producing a response has no effect on US presentations. Comments Operant Conditioning procedures can be used to 1. Increasing a behaviour a. Positive Reinforcement b. Negative Reinforcement c. Modeling 2. Decreasing a behaviour a. Time Out b. Punishment c. 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