ccd

CLINICAL CASE DISCUSSION

Dr M Nadeem Zafar
• Q1. A 50 year old man is diagnosed by carcinoma of head of the
pancreas. Which of the following structure is in close proximity with
the head of pancreas?

• A. Left Kidney
• B. Pylorus
• C. Common bile duct
• D. Splenic artery
Ans: C
• CBD lies in close relation to head of pancreas.
• The initial presentation on about 70% of patients with carcinoma of
the head of the pancreas is jaundice due to obstruction of the CBD by
the tumour.
• Q2. A 45 year old man presents to the clinic with herpes zoster over
the dermatome of the maxillary branch of the trigeminal nerve.
Which type of mucosa will be affected along with the dermatome?

• A. Palate
• B. Lower lip
• C. Conjunctiva
• D. Anterior 1/3 of the tongue
Ans: A
• Pay attention, the question asks about which MUCOSA the maxillary
branch of the trigeminal nerve innervates so the best answer will
therefore be palate as it is a mucous membrane.

• The soft palate consists of muscle fibers and connective tissue

covered by a mucus membrane consisting of a stratified squamous
epithelium with secretory salivary glands.
• Q3. A 35 year old man sat cross-legged for 30 minutes after which
he found himself unable to dorsiflex his left foot and had loss of
sensation in the web space between the big toe and the second toe.
What is the most likely anatomical structure to be affected?

• A. Femoral nerve
• B. Superficial peroneal nerve
• C. Sciatic nerve
• D. Deep peroneal nerve
Ans: D

Deep peroneal nerve (Deep fibular nerve)

• Motor functions: The deep peroneal nerve innervates the muscles in
the anterior compartment of the leg which are responsible for
dorsiflexion of the foot at the ankle joint.

• Sensory functions: The deep peroneal nerve innervates the webbed

space of skin between the great toe (hallux) and the second toe
• Wrist drop → Radial nerve
• Foot drop → Either common peroneal nerve or sciatic nerve
• Claw hand → Ulnar nerve
• Paraesthesia of thumb, index and middle finger → Median nerve
Numbness on superior aspect of upper arm just below shoulder joint →
Axillary nerve
• Fibular neck fracture → Common peroneal nerve
• Femur neck fracture or Acetabular fractures → Sciatic nerve
• Fracture of humeral shaft → Likely Radial nerve
• Fracture of humeral neck → Likely Axillary nerve
• Monteggia fracture → Radial nerve
• Q4. A 60 year old man underwent surgery for varicose veins of the
leg. He is now complaining of numbness on the medial side of his
foot. What is the most likely nerve involved?

• A. Common peroneal nerve

• B. Tibial nerve
• C. Sural nerve
• D. Saphenous nerve
Ans: D
• Loss of sensations in medial foot: Saphenous
• Nerve Loss of sensations in lateral foot: Sural nerve
• Foot drop: Common peroneal nerve

• The Saphenous nerve is the largest cutaneous branch of the femoral nerve
and is a strictly sensory nerve with no motor functions.

• Surgery for varicose veins, saphenous vein cutdown and orthopedic

surgery can result in damage to the saphenous nerve, resulting in loss of
cutaneous sensation in the medial leg. It can also be damaged during vein
harvest for bypass surgery and during trocar placement during knee
arthroscopy.
• Q5. Which of the following important landmark is found above the
5th intercostal space and anterior to the mid axillary line?

• A. Apex beat
• B. Chest drain insertion
• C. Stellate ganglion
• D. Transpyloric plane
Ans: B
• This landmark is especially important when attempting to insert a
chest drain.

• Always look for the safe triangle when inserting chest drains.

• Insert the drain in an area anterior to mid axillary line, posterior to

pectoral groove, and above the 5th intercostal space.
Q6. A 50 year old female operated for breast carcinoma. After radical
mastectomy, there was injury to the long thoracic nerve. Surgeon
wants to check integrity of the nerve. It can be tested at bedside by
asking the patient to:

a. Touch the opposite shoulder

b. Lift a heavy object from the ground
c. Raise the arm above the head on the affected side
d. Shrug the shoulders
Ans: C

ABDUCTION OF ARMS
0° - 15° Supraspinatus Muscle
15° - 90° Deltoid Muscle
> 90° Serratus anterior and Trapezius
muscle
1. Dorsal Scapular Nerve (C5): Supplies muscles attached to the dorsal side
of medial border of scapula.

2. Long Thoracic Nerve (C5, C6, C7) : Supplies Serratus Anterior (inserted on
the coastal surface of medial border of scapula
(Nerve of bell & Nerve to Serratus Anterior)
BRANCHES FROM ROOTS:
Long Thoracic Nerve (C5, C6, C7) : Supplies Serratus Anterior
(inserted on the coastal surface of medial border of scapula
(Nerve of bell & Nerve to Serratus Anterior)
Contraction of S. Anterior helps in pushing the scapula forward –
Punching Movement – a/c/a BOXER’S MUSCLE
- It also helps in overhead abduction of shoulder
CLINICAL ASPECTS:
Injury of Long Thoracic Nerve: During Radical Mastectomy & Axillary
LN dissection – WINGING OF SCAPULA (scapula fails to move forward –
Medial Border of scapula goes backward & becomes prominent)
Q7. During a fight, a person gets injured in the neck region with a
knife and presents to emergency department with weakness in
raising arm above the head. On further examination winging of
scapula is noted. Which of the following nerves got injured during the
fight?

a. Suprascapualr nerve
b. Dorsal scapular nerve
c. Lateral pectoral nerve
d. Long thoracic nerve of bell
Ans: D
Injury of Long Thoracic Nerve: During Radical Mastectomy & Axillary
LN dissection – WINGING OF SCAPULA (scapula fails to move forward –
Medial Border of scapula goes backward & becomes prominent)
• Q8. A 45 year old woman came with a large abscess in the middle of
the right posterior triangle of the neck. General surgeon incised and
drained the abscess. Six days later, patient noticed that she could
not extend her right hand above her head to brush her hair. Which
of the following are the signs and symptoms of additional harm?

• A. Damage to scalenus muscle

• B. Cut injury to spinal part of accessory nerve
• C. Injury to suprascapular nerve
• D. spread of infection to shoulder joint
Ans: B
• Spinal accessory nerve runs superficial in the posterior triangle of
neck and prone to iatrogenic injury. Eg: I & D of an abscess.

• Nerve lesion causes paralysis of Trapezius muscle leading to

difficulty in overhead abduction and shrugging of shoulder.

Note:
• Injury to suprascapular nerve leads to paralysis of supraspinatus and
infraspinatus, resulting in weakness of abduction and lateral rotation
at the shoulder joint
BRANCHES FROM TRUNKS: Only from
upper trunk
1. Suprascapular Nerve (C5, C6)
Supraspinatus muscle (helps in abduction of arms 0° - 15°)
Infraspinatous muscle
ABDUCTION OF ARMS

0° - 15° Supraspinatus Muscle

15° - 90° Deltoid Muscle
> 90° Serratus anterior and Trapezius muscle

2. Nerve to Subclavius (C5, C6)

It supplies subclavius muscle.
It gives off accessory phrenic nerve
UT: C5, C6

LT: C8, T1:

Complete claw hand
Horner’s syndrome
• Q9. During a cricket match, a batsman was hit by the ball on his
head and lost consciousness momentarily. He quickly regained his
senses, composed himself and continued with the play. A while later
he again fell unconscious and was rushed to the hospital this time.
Which of the following blood vessels can be affected in his case?

• A. Bridging veins
• B. Middle Meningeal artery
• C. Lenticulo-striate branch of MCA
• D. Arterial aneurysm
Ans: B (Case of lucid interval – seen in EDH)
EXTRADURAL SUB DURAL SUB INTRACEREBR
ARACHNOID AL
Location Between skull Between dura Between Within the
and dura and arachnoid arachnoid & brain
Pia parenchyma
Most common MIDDLE BRIDGING Arterial Lenticulo-
vessel affected MENINGEAL VEINS aneurysms, striate branch
ARTERY AV of MCA
Malformation
Q10. After the injury over right shoulder, a patient is avoiding abducting his
shoulder because of pain. He has dull ache on his affected shoulder and has
difficulty sleeping over the same shoulder. X-ray of Right shoulder didn’t find
any fracture. Clinician is doing the following test as shown in photo. Which
tendon injury he is suspecting?

a) Supraspinatus
b) Infraspinatus
c) Teres minor
d) Subscapularis
Answer: D
Diagnosis: Rotator Cuff injury
Shown test is: Lift Off Test/GERBER’S TEST

• Lift off Test: to assess the

strength of SUBSCAPULARIS
MUSCLE & a rupture of the
SUBSCAPULARIS TENDON.
HOW TO PERFORM THIS TEST?
• Extended arm and internally rotated, such that the dorsum of hand
rests against the back. (SUBSCAPULARIS IS MAXIMALLY ACTIVE IN
THIS POSITION)

• Now instruct the patient to lift his hand off the back.

• If he can – Then test is negative

• If he can’t – Then test is positive
Q11. The test shown in photo is performed to check the strength of
which muscle?

A. Opponens policis
B. Flexor pollicis brevis
C. Flexor policis Longus
D. Adductor pollicis
Answer: D
• FROMENT’S SIGN: to check ulnar nerve injury

(BOOK TEST)
• It tests the strength of the adductor pollicus of the thumb, which is
innervated by the ulnar nerve and is weakened in ulnar nerve palsy.
• Loss of abduction and adduction of fingers – CARD TEST POSITIVE
(ulnar nerve injury)

• Loss of adduction of thumb – FROMENT SIGN POSITIVE (ulnar nerve

injury)

• Inability to adduct the small finger in against the ring finger -

WARTENBERG’S SIGN (ulnar nerve injury)

• Index finger fails to flex on clasping hand – POINTING INDEX or

OSCHNER’S CLASP TEST (median nerve injury)
Q12. A 45 year old female has undergone mastectomy for Cancer
Breast. After mastectomy , patient is not able to extend, adduct and
internally rotate the arm. Nerve supply to which of the following
muscles is damaged?

A. Teres Minor
B. Pectoralis major
C. Latissimus Dorsi
D. Long head of triceps
Answer: C

• Latissimus dorsi – CLIMBER’S MUSCLES – as it comes in visible action

in climbing up the trees, so also in swimming and rowing.

• Latissimus Dorsi causes Adduction, Extension and Medial (Internal)

rotation of humerus/shoulder.
Q13. A patient presents to the emergency department with severe
complain of pain going down the leg from the lower back. She has the
history of intramuscular injection at the gluteal region by an
inexperienced healthcare worker. Which nerve is mostly involved in
this case?

A. Femoral nerve
B. Lateral cutaneous nerve of thigh
C. Sciatic nerve
D. Obturator nerve
Answer: C
SCIATIC NERVE may be injured in;
• Misplaced intramuscular injection (most common cause)
• Posterior dislocation of hip
• Fracture of pelvis
• Hip surgery
• Piriformis syndrome ( anomalous relationship between muscle & nerve)

• Intramuscular injection– to be injected in G. Medius (rather than G.

Maximus)

• Alternative – lateral aspect of thigh ( vastus lateralis)

• IM – to be injected in G. Medius (rather than G. Maximus)

• Alternative – lateral aspect of thigh ( vastus lateralis)

Q14. Which of the following muscle is involved in movements from
sitting to standing position?

A. Gluteus minimus
B. Gluteus Medius
C. Gluteus Maximus
D. Obturator internus
Answer: C
• Gluteus maximus extends and laterally rotates the hip.

• It helps to maintain knee in extension through iliotibial tract.

• It is most commonly used as an extensor of trunk on thigh, as when

raising the trunk from sitting position.
• Q15. A camel rider sustained an injury to the lateral side of his right leg
just below the knee caused by the camel stick. The site is slightly bruised
and tender to touch. He is unable to either dorsiflex or evert the foot.
There is loss of sensation over the front and outer half of the leg and
dorsum of the foot. What is the most likely anatomical structure to be
affected?

• A. Sural nerve
• B. Common peroneal nerve
• C. Tibial nerve
• D. Lateral plantar nerve
Ans: B
• This is actually called a peroneal strike.

• A peroneal strike is a temporarily disabling blow to the common

peroneal nerve of the leg, just above the knee which causes a
temporary loss of motor control of the leg, accompanied by
numbness and a painful tingling sensation from the point of impact
all the way down the leg, usually lasting anywhere from 30 seconds to
5 minutes in duration.
• Q16. A 24 year old patient was lying down on the operating table in a
position with his arms hanging down for 3 hours. Soon after he woke up,
he complains of numbness and weakness on his left hand and has a wrist
drop. There is a loss of sensation over a small area between the dorsal
aspect of 1st and 2nd metacarpals. What is the most likely structure to be
damaged?

• A. Radial nerve
• B. Median nerve
• C. Ulnar nerve
• D. Axillary nerve
Ans: A
• Wrist drop – radial nerve injury
• Q17. A 52 year old man underwent a hemicolectomy. A few days
after his operation he develops chest pain and a temperature of
38.8°C. He is having rigors and night sweats. On auscultation, a
systolic murmur is heard. What is the next most appropriate
investigation?

• A. Computed tomography scan of the chest

• B. Abdominal ultrasound
• C. Chest X-ray
• D. Blood culture
Ans: D
• This is a case of infective endocarditis.
• The most appropriate investigation is blood cultures or
echocardiogram.
• Since echocardiogram is not one of the options, blood cultures should
be picked.

• Infective endocarditis- Fever + new murmur = endocarditis until

proven otherwise
Diagnosis Infective endocarditis is diagnosed if
• 2 major criteria present,
• or 1 major and
• 3 minor criteria present, or
• 5 minor criteria present

• Major criteria
• Positive blood cultures
• Positive echocardiogram - showing abscess formation, new valvular regurgitation

• Minor criteria
• IV Drug user, predisposing heart condition, Fever >38°C, Vascular phenomena: e.g. major
emboli, clubbing, splinter haemorrhages, Janeway lesions, Immunological phenomena:
glomerulonephritis, Osler's nodes, Roth spots, Microbiological evidence does not meet
major criteria
• Q18. A 24 year old female is admitted in hospital with high grade fever,
vomiting, flank pain with increased frequency of micturition for last 3
days. Her urine specimen is collected in a sterile container and sent for
microscopy, culture and sensitivity testing. Which of the following wrong
statement related to this case?

• A. Infection is considered when there is count > 1,00,000/ml CFU

• B. CLED agar is the culture medium preferred for processing of urine
specimen
• C. Infection is till urethra
• D. Mostly Gram –ve bacteria
Ans: C
UPPER UTI LOWER UTI

Sites Kidney and ureter Urethra and bladder

Symptoms Local and Systemic Local manifestations:

manifestations; Dysuria, Urgency, Frequency
Fever, vomiting, abdominal
pain
Route of Ascending and descending Ascending
spread
• MCC of UTI in all forms: G –ve (E.coli, Klebsiella, Proteus etc.)

• Culture: MacConkey agar and Blood agar or CLED (cycteine lactose

etectrolyte deficient agar)

• A count of ≥ 100000 CFU (colony forming units - CFU) considered as

significant – indicates infection

• Treatment of UTI: Norfloxacin, nitrofurantoin, Cephalosporin

• Q19. A patient presented with swelling in knee with severe
tenderness, redness, swelling, inability to move the limb and fever.
On examination, affected area is warm. Patient does not remember
any history of trauma. Which of the following is correct as per
clinical conditions and images as shown below?

• A. A case of fracture
• B. Fungal infection
• C. Bacterial infection
• D. Haematological pathology
Ans: C
• Clinical Conditions depict: SEPTIC ARTHRITIS.

• A hot swollen joint without trauma is Septic arthritis until proven

otherwise.
S. aureus is MMC of various conditions:
• Septic arthritis (MC involving knees, shoulders, hips and phalanges)

• Osteomyelitis (MC in children – long bones, Adults – vertebrae)

• Pyomitis (skeletal muscle infection): in tropics and HIV infected

people

• Abscess: Psoas abscess and epidural abvscess

• Q20. A person suffered from a small injury over his left thumb. After
2-3 days, there was acute onset and rapid progression in wound as
shown in photo. Patient is complaining of severe pain, malaise,
fever and chills. Which of the following is the most probable
causative agent for this condition?

• A. S. Aureus
• B. E. coli
• C. Group A streptococcus
• D. Group B streptococcus
Ans: C
• Clinical condition and acute progression of wound show
NECROTIZING FASCITIS.

MCC is Streptococcus Pyogens. It is the only species under

Lancefield’s group A Streptococcus.

Source of infection:
• 1. Traumatized skin: MCC is S. Pyogens (sometimes with S. Aureus)
• 2. Gastrointestinal breach: due to abdominal surgery
Cellulitis Erysipelas Necrotising Fascitis
• Q21. A 30 year old male presented in hospital with high fever ,
headache, drowsiness, mental confusion. On examination, neck is
stiff. Suspecting meningitis, cytopathological examination (Tzank
preparation) is performed, which detects multinucleated giant cells.
what is the most probable causative agent?

a. Neisseria Meningitidis
b. Neisseria Gonorrhoeae
c. Herpes Simplex Virus
d. Moraxella
Ans: C
• HSV is the MCC of acute sporadic viral encephalitis, most frequently involving
temporal lobe.
• HSV-1 (95%) is more common than HSV-2

• Children get primary infection: HSV is acquired exogenously and invades CNS via
the olfactory bulb.
• Adult get recurrent infections due to reactivation of HSV in trigeminal nerve

• HSV can cause meningitis called MOLLARET’S MENINGITIS

• HSV - Cytopathology (Tzank preapartion) by Wright’s or Giemsa stain detects

inclusion bodies (Lipschultz body) & formation of multinucleated Giant cells)
• Q22. A 45 year male chef gets fever once in 2-3 months. He also gets
headache, chills, abdominal pain, myalgia, rashes, nausea and
vomiting. Fever rises gradually to a higher level with every spike,
then falls down but does not touch normal. A surgeon performed
cholecystectomy in that patient. What is the reason for surgery in
this case?

• A. Causative agent is Aedes aegypti

• B. Colonization of Salmonella Typhi is more in higher concentration
of bile juice
• C. Salmonella typhi is resistant to bile juice
• D. It is a case chikungunya fever
Ans: B
• This is a case of TYPHOID
• And patient is a chronic carrier of typhoid fever/enteric fever, Caused by
Salmonella Typhi

• Typhoid bacilli multiply in the gall bladder and are excreted in feces. Fecal
carriers are more common.

Chronic carriers occur in 1-4% of infected people. Chronic carriage is more

common in:
• 1. Woman, infants and old age
• 2. Biliary tract abnormalities which leads to increased fecal excretion
• Q23. A 35 year old male truck driver with history of multiple sex
partners is admitted with complaints of unexplained fever,
progressive weight loss, persistent diarrhea with generalized
lymphadenopathy for the past 6 months. Most probable causative
agent is a:

• A. Picornavirus
• B. Herpesvirus
• C. Paramyxovirus
• D. Retrovirus
Ans: D
• Clinical conditions correlate with HIV, caused by Retrovirus.
• Q24. In order to minimize the risk of transmission of infection, donning
(wearing) and doffing (removing) of PPE must be performed in a
particular sequence. Find out the correct sequence:

• A. Donning: Gloves first – Face shield or goggles – Gown – Mask or

respirator
• B. Doffing: Gown first - Mask or respirator –Goggles or face shield –
Gloves
• C. Donning: Gown first - Mask or respirator –Goggles or face shield –
Gloves
• D. Doffing: Gown – Face shield or goggles – Gloves first – Mask or
respirator
Ans: C
Donning (Wearing): Gown first - Mask or respirator –Goggles or face
shield – Gloves

Doffing (Removing): Gloves first – Face shield or goggles – Gown –

Mask or respirator

Hand rub: should be performed minimum for 20 seconds

Hand wash: should be performed minimum for 40 seconds
• Q25. A patient with BPH was admitted in hospital for
3 weeks. He subsequently developed suspected
catheter associated UTI. Tip of the catheter was sent
for culture and was grown on blood agar. After 24
hours, the blood agar shows the appearance as
shown here. What is the most likely causative agent
for the UTI?

• A. Pseudomonas
• B. Klebsiella Pneumoniae
• C. E. coli
• D. Proteus Mirabilis
Ans: D
• Swarming of proteus on solid media (eg blood agar) appears in two
patterns.

1. Uniform film of growth extended on the whole plate (continuous

swarming)

2. Concentric circles of growth surrounding the point of inoculum

(discontinuous swarming)
• DIENES PHENOMENON: When two strains of proteus are inoculated
at different areas on a culture plate:

1. If swarming of strains merge incompletely, and remain separated by

a narrow line of demarcation – indicates two strains are different.
2. If swarming of two strains merge completely without any line of
demarcation – indicates two strains are identical.
 TYPES OF MOTILITY SHOWN BY DIFFERENT BACTERIA
Tumbling Motility Listeria
Stately motility Clostridium
Gliding motility Mycoplasma
Darting motility V. Cholera
Campylobacter
Swarming on agar plate Proteus
Clostridium Tetani
Corkscrew, Lashing, Flexion, Spirochete
Extension motility
• Q26. A 2 year old child presented to hospital with tenesmus,
abdominal pain and passage of bloody diarrhea with mucus, eight
times for the past 2 days. This is suggestive of;

• A. Cholera
• B. Dysentery
• C. Food poisoning
• D. Diarrhea
Ans: B
CLINICAL TYPES OF DIARRHEA
1. Diarrhea ≥ 3 loose stools/day
- Inflammation of mucous membrane of stomach
2. Gastroenteritis/Infectious diarrhea and intestine resulting in combination of;
Diarrhea, Vomiting and pain abdomen with or
without mucus/blood/fever/dehydration

3. Dysentery Diarrhea + Increased blood & mucos, often

associated with fever, abdominal pain and
tenesmus ( a feeling of incomplete defecation)
4. Food poisoning Foods/drinks contaminated with micro-
organisms

Group of patients with Fever, Vomiting and

diarrhea

5. Traveler's diarrhea
• Q27. A patient is admitted with the complaints of 3-4 loose stools
per day with bloating. His daily routine activities are getting
affected. What should be the better line of management?

• A. Fluids + Lactose free diet + antacid

• B. Fluids + Loperamide + adsorbent (bismuth subsalicylate)
• C. Fluids + Loperamide + Antibiotics + Antacids
• D. Admit the patient + IVF + IV antibiotics
Ans: B
TYPES OF DIARRHEA DEFINITION MANAGEMENT

MILD 1 – 2 unformed stools per day Hydration: Fluids

Minimal symptoms Lactose-free diet and avoid
No interference with daily caffeine
routine activities No antibiotics required
MODERATE 3 - 5 unformed stools per day Fluids + Anti-motility agents
With/without symptoms (Loperamide) +
Interference with daily routine Adsorbents (bismuth
activities subsalicylate)
No antibiotics required

SEVERE ≥ 6 unformed stools/day +/- Empirical: Ciprofloxacin or

Fever, tenesmus, blood or fecal Levofloxacin for 3-5 days
leukocytes
Antibiotics as per the req.
• Q28. A 9 year old girl is admitted to the hospital with complaints of high
grade fever, headache, vomiting, altered mental status, seizure and neck
rigidity. CSF analysis is collected by lumbar puncture in a sterile container
and sent to lab for biochemical analysis, direct microscopic test, culture
and sensitivity testing. What can be the most probable causating agent?

• A. Streptococcus pneumoniae
• B. Neisseria meningitidis
• C. E. Coli
• D. Listeria Monocytogenes
Ans: B
CAUSES OF PYOGENIC MENINGITIS
Neonates or 0 – 2 years infants E.Coli
Grp B Strep (S. Agalactiae)
Klebsiella
Listeria Monocytogenes
2 – 20 years Neisseria Meningitidis (MC)
H. Influenza
Strep. Pneumoniae
> 20 years (adults) Strep. Pneumoniae (MC)
H. Influenza
N. Meningitidis
>60 years (elderly) Listeria Monocytogenes
Overall MC: Strep Pneumoniae
• Q29. A 45 year old female presented with fever, chills and rigors,
difficulty in breathing, anxiety, malaise, vomiting and confusion.
O/E, following signs were noticed; Body temperature 102 °F, HR
106/min, RR 22/min. Urine output was significantly decreased.
What is the probable clinical diagnosis?

• A. Typhoid
• B. Meningitis
• C. Sepsis
• D. Very high fever of unknown reason
Ans: C
• As per SOFA (sepsis related organ failure);

• Patient presented with fever, alteration in mental status, HR 106/min

and RR 22/min satisfies quick SOFA criteria of sepsis

• SOFA: to asses the severity of infection and extent of organ failure

• Q30. A 14 year old boy is on central line presented with fever (>103 °F),
mental confusion, HR 102/min and RR >24/min. Blood was collected both
from central line and peripheral line separately in BacT/ALERT bottles and
sent for culture. Both central line & peripheral line bottles flagged
positive for E.coli after 4 hours and 7 hours of incubation respectively.
What is the clinical diagnosis?

• A. Infective endocarditis
• B. Cerebral malaria
• C. Post operative complication
• D. Catheter related blood stream infection
Ans: D
• This is a case of CRBSI
• Patient is on central line
• All signs of sepsis are present. Culture is also positive
• Q31. A 60 year old diabetic male patient is admitted in the hospital
with complaints of swelling in the arm with pus discharge. On
physical examination, the local area was red, warm and tender. The
swelling has a feel of fluid – filled when pressed. What is the correct
statement related tot his case?

• A. Empirical antibiotics are supportive

• B. Change the anti-diabetic medication
• C. Its an abscess, so I and D with antibiotics are supportive
• D. This is a case of necrotizing fasciitis
Ans: C
• This is an abscess

• Mx: I & D + antibiotics

• Q32. A new drug is launched in the market. Many side effects of this
drug are reported in nearby district hospitals of various states in
India. Which software is used to report all these side effects of this
drug?

• A. VIGIFLOW
• B. VIGIBASE
• C. iCloud
• D. CDSCO
Ans: A
• ADR (adverse drug reposting system)
• Pharmacovigilance is conducted by CDSCO (Center for Drug Standard
Control Organization), Delhi

• Any ADR detected throughout India in hospitals and medical colleges

is reported to the NCC through a software VIGIFLOW.

• VIGIBASE: worldwide drug safety database of pharmacovigilance

• Q33. A child presented with history of some unknown plant and
developed mydriasis, tachycardia, dry mouth, warm skin and
delirium. Which of the following group of drugs is likely to be
responsible for the symptoms of this child?

• A. Opioid
• B. Sympathomimetic
• C. Benzodiazepine
• D. Anticholinergic
Ans: D
• Cholinergic: pupil constriction; increased salivary, lacrimal, and
bronchial secretions; smooth muscle stimulation; urinary bladder
stimulation; improved muscle tone/strength
• Q34. A 70 year old male presents for the first time with complaints
of dribbling of urine, frequency and hesitancy. O/E, his prostate is
enlarged. Shown medicine is given to the patient. Which of the
following is a correct statement related to this drug?

• A. It increases the muscle tone

• B It prevents the conversion of testosterone
into dihydrotestosterone
• C. It relaxes the smooth muscle fibers
• D. It is the 2nd line drug to be given in BPH
 Ans: C
MEDICAL THERAPY OF BPH
1. Alpha Blockers: (Prazosin, Terazosin, Tamsulosin, Doxazocin, Silodosin and Alfuzosin) –
Immediate action is seen
• They relax smooth muscle tone (bladder neck, prostate and prostatic urethra) and reduce
obstruction – Increase urinary flow rate

• 2. 5 alpha reductase inhibitors (Finasteride, Dutasteride)

• They prevent conversion of testosterone into more active dihydrotestosterone
responsible for androgen action in prostate. Their use results in reduction of size of the
gland and improvement in the symptoms.
• 6 months required to see the max effect (Minimum 1 month)

Both can be given together when there is;

• Enlarged prostate and increased PSA
Q35. A 60 year old female is on long term medication
for peptic ulcer disease. She presents to your clinic
with severe pain in pelvic region with inability to walk.
X-ray is done and following picture came out. Which of
the following drugs can cause this?

a. Cimetidine
b. Rabeprazole
c. Sucralfate
d. Misoprostol
 Answer: B
• PPI (Proton Pump Inhibitors) are the most effective anti-acid secretory
agents as they block the terminal step in HCl secretion, i.e. proton
pumps (H+K+ ATPase).
• Eg; Pantoprazole, Omeprazole, Lansoprazole and Rabeprazole.

• Pantoprazole is the most acid stable and rabeprazole is most acid

labile PPI.

• Rabeprazole is the most potent, longest and fastest acting PPI.

• PPIs are DOC for treatment of peptic ulcer disease, NSAID induced
ulcer, stress ulcer, Zollinger-Ellison syndrome, GERD.

• Long term therapy decreases absorption of calcium (osteoporosis, HIP

FRACTURE), iron, Vit. B12 and magnesium.
• Q36. A patient is on DMARD, presented with mild sight loss.
Following presentation is seen on examination. Similar picture of
eye can be seen as a side effect of which of the following class of
drug?

• A. Anti Tubercular drug

• B. Anti Malarial drug
• C. Anti Fungal drug
• D. Anti RetroViral drug
Ans: B
• Shown picture is BULL’S EYE RETINOPATHY – associated with Choroquine.

• Chloroquine is the DOC for treatment & prophylaxis of malaria except P.

Falciparum malaria.

• Other uses of chloroquine: Amebiasis, Giardiasis, Infectious

mononucleosis, SLE, DLE and Rheumatoid arthritis.

• Side effects are: Convulsions, Bull’s eye retinopathy, hypotension,

hemolysis in G6PD deficiency, Myopathy and QRS & T wave abnormalities
in ECG.
• Q37. Post COVID-19, a 56 year old male presents with exertional
dyspnea and non productive cough. Which of the following drugs is
useful in this condition?

• A. Bleomycin
• B. Pirfenidone
• C. Heparin
• D. Steroids
Ans:B
• Pirfenidone (5-methyl-1-phenyl-2-[1H]-pyridone), is a novel anti-fibrotic agent
with trivial adverse effects.

• Pirfenidone is approved for the treatment of Idiopathic Pulmonary Fibrosis (IPF)

for patients with mild to moderate disease.

• It works by reducing lung fibrosis through downregulation of the production

of growth factors and procollagens I and II.

• Pirfenidone could inhibit apoptosis, downregulate ACE receptors expression,

decrease inflammation by several mechanisms and ameliorate oxidative stress
and hence protect pneumocytes and other cells from COVID-19 invasion and
cytokine storm simultaneously
• Q38. A 55 year old male patient presented with non productive
cough and dyspnea on exertion. On history taking, it is confirmed
that patient was on anticancer treatment for Hodgkin’s one year
before. Which of the following drugs might have caused the finding
seen on chest X-ray shown here?

• A. Dacarbazine
• B. Doxorubicin
• C. Vinblastine
• D. Bleomycin
Ans: D
• X-ray shows Pulmonary Fibrosis

• ABVD regimen for Hodgkin’s disease: Adriamycin/Doxorubicin +

Bleomycin + Vinblastine + Dacarbazine)

• Bleomycin can cause pulmonary fibrosis

 Pulmonary Fibrosis Causes are:
SCAR: Upper Lobe SCAR: Lower Lobe DRUGS
Sarcoidosis/silicosis Systemic sclerosis Amiodrone
Coal worker Cryptogenic Fibrosing Acyclovir
pneumoconiosis Alveolitis Azathioprine
Ankylosing Spondylitis Asbestosis
Radiation Rheumatoid arthritis Busulfan
Bleomycin
Tuberculosis
Cyclophosphamide
Chlorambucil
Carmustine
• Q39. A 54 year patient has cough with sputum for last 15 days, fever
and night sweats. On investigations, ESR is raised and AFB +ve seen.
His X-ray is shown here. Clinician started him on treatment.
Following the therapy, he developed tingling sensation on lower
limb. Which of the following when substituted can result in
improvement of symptoms?

• A. Vitamin B12
• B. Thiamine
• C. Folic acid
• D. Pyridoxine
 Ans: D
• Pyridoxin is given together with ATT (isoniazid/ethionamide) to
prevent drug related peripheral neuropathy.

• Isoniazid inhibits pyridoxal phosphokinase, resulting in pyridoxine

deficiency and the neuropathy.

• Prophylactic administration of pyridoxine 100mg/dl can prevent the

neuropathy from developing. Harrison 19/e
• Q40. An obese diabetic woman was on failed metformin therapy.
She has history of pancreatitis and family history of bladder cancer.
She is not willing to take injections. Which of the following drug
would be suitable to decrease her glucose level?

• A. Sitagliptin
• B. Liraglutide
• C. Canagliflozin
• D. Pioglitazone
 Ans: C
• Sitagliptin increases the risk of acute pancreatitis.
• Pioglitazone is associated with a small increased risk of bladder cancer
• Liraglutide is given subcutaneously.

• (Note: TERIPARATIDE – osteoporosis drug – high risk of osteosarcoma in future)

• Canagliflozin, is a SGLT-2 (sodium glucose Co-Transporter 2 inhibitors), given

orally and it reduces body weight.

• SGLT-2 inhibitors are: CANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN

• SGLT-2 inhibitors have been found to reduce systolic BP, uric acid and weight.
These are neutral to lipid.
• Q41. which of the following is the most appropriate instruction to
be given to a lactating mother regarding drug use?

• A. To feed the baby just before next dose

• B. To feed when it is least efficacious
• C. to take drugs with longer t ½
• D. no advice is required as most of the drugs are secreted negligibly
in the milk
Ans: A

RECOMMENDED METHODS OF REDUCING INFANT EXPOSURE TO DRUGS DURING

BREASTFEEDING
For drugs that do not have to be avoided For drugs that should not be given to
but should have levels reduced infants

Feed your baby right before taking the Switch the infant to formula feeding
next dose of the drug – so the baby temporarily or to breast milk obtained
receives the lowest possible drug when you were not taking the drug.
concentration.
• Q42. After treatment for glaucoma, a patient comes to emergency
department with acute bronchial asthma. Which drug might have
caused this?

• A. Latanoprost
• B. Timolol
• C. Betaxolol
• D. Anticholinesterase
Ans: B
• Beta blockers like Timolol by blocking beta 2 receptors can precipitate
bronchial asthma.
• Q43. A 51 year old man is diagnosed with hypertension. He is a
known case of asthma. His potassium and creatinine are slightly
elevated. Which of the following medicines would be more
appropriate in his case?

• A. Spironolactone
• B. Amlodipine
• C. Propanolol
• D. Hydrochlorthiazide
 Ans: D
• Spironolactone cannot be used as there is hyperkalemia

• Propanolol should be avoided as patient has bronchial asthma

• Amlodipine & hydrochlorthiazide can be used. But hydrochlorthiazide

is more preferred as it can cause hypokalemia and blunt the
hyperkalemia.
• Q44. A 38 year old male presents to the clinic with complaint of pain in
the right side of jaw. Each episode of pain is lasting for around 30
seconds. He informs that episodes of pain are increasing day by day. And
these episodes are specially increasing when he walks in cold. What is
the mechanism of action of the drug of choice for this condition?

• A. Decrease in calcium influx

• B. Prevention of Na+ influx
• C. increase the chloride channel opening
• D. Increase the duration of chloride channel opening
 Ans: B
• Clinical scenario depicts TRIGEMINAL NEURALGIA.

• DOC is CARBAMAZAPINE – It is a sodium channel blocker

• Q45. A patient who is on treatment for trigeminal neuralgia is
recently diagnosed with schizophrenia. Which of the following acts
as a limiting factor in the use of clozapine as an antipsychotic drug in
this patient?

• A. High incidence of extrapyramidal symptoms of schizophrenia

• B. Not beneficial in reducing negative symptoms of schizophrenia
• C. It can cause agranulocytosis
• D. It is typical antipsychotic
 Ans: C
• Clozapine can cause agranulocytosis.

• Agranulocytosis is the grave side effect of Carbamazepine which is the

DOC for trigeminal neuralgia

• Hence clozapine should be avoided.

• Q46. A patient is brought to the emergency department with severe
bradycardia, drowsiness, feeble pulse and very low blood pressure.
The patient was found to have consumed unknown quantity of his
anti-hypertensive medication. Which of the following cannot ne the
medication?

• A. Digoxin
• B. Hydralazine
• C. Clonidine
• D. Reserpine
Ans: B
• Hydralazine is an arterial dilator which will cause reflex tachycardia.

• Remaining all drugs can cause bradycardia.

• Clonidine is a central sympatholytic which can cause bradycardia.
Same is the case with reserpine which decrease NE synthesis.
• Digoxin can also cause given symptoms as it has parasympatholytic
effect
• Q47. A girl with h/o getting medications prescribed psychiatrist for
depression. She presents to hospital with altered sensorium, ECG
shows QRS widening and right axis deviation > 120° in terminal part.
What is the line of management?

• A. I/V Flumazenil
• B. Charcoal
• C. Hemodialysis
• D. I/V sodium bicarbonate
Ans: D
• This is a case of TCA toxicity.

• Treatment is I/V sodium bicarbonate.

• Q48. Which of the intravenous fluids is not a crystalloid solution?

• A. Hartman’s solution
• B. Normal saline
• C. Dextran
• D. Dextrose
Ans: C
 IV Fluids
CRYSTALLOIDS COLLOIDS BLOOD PRODUCTS
Normal Saline Albumin Blood
Ringer’s Lactate Platelet
Dextrose Dextran Plasma
Hartman’s solution Starch FFP
Plasmalyte Gelatin

NS RL
Na: 154 Meq/L Na: 130, Cl: 109
Cl: 154 Meq/L K: 4
Ca: 3
Lactate: 28
• Q49. After an RTA, a person is admitted in hospital. He has
hypotension after loss of approx. 2L blood. Which of the fluids to be
given till the time blood is getting arranged?

• A. NS
• B. RL
• C. Colloid
• D. DNS
Ans: C
Choice of fluids:
• 1. Dehydration: Oral/Ryle’s tube – Clear water is best
• 2. Diarrhea: RL
• 3. Vomiting: NS
• 4. Blood loss: Blood > crystalloids (3:1)
• 5. Blood loss with hypotension: Colloid till blood is available
• 6. Poor nutrition: Oral/Ryles tube (↑Protein diet) > TPN
• Q50. A patient is presented to hospital after RTA. Patient had blood
loss. O/E BP - 90/60 mmHg, PR – 110/min, RR – 18/min. SpO2 – 94.
what is the better line of management?

• A. Infuse bolus 1L IV fluid in 15 minutes

• B. Transfuse 1 unit of blood
• C. Send Blood sample for Hb, blood grouping and matching and start
the patient on blood transfusion
• D. 500 ml IVF over 15 minutes and repeat if no response
Ans: D
• How to start and maintain IVF (NICE guidelines)

Hypovolemic shock
↓
500 ml over 15 minutes and repeat if no response (1-2 L NS over 1 hr)
↓
Ongoing loss + urine output + 50 – 100 ml/hr
↓
Maintenance fluid: 30ml/kg/d of water
1 mmol/kg/d of Na, K, Cl
100 g glucose/d
• Q51. IVF Normal saline can be given in all given conditions except:

• A. Hyponatremia
• B. Metabolic acidosis
• C. Vomiting
• D. Brain edema after trauma
Ans: b
• NS causes acidosis, so it should be avoided in Metabolic acidosis
• Q52. What is the better way to measure the length of feeding tube
to be inserted for transpyloric feeding?

• A. Nose to umbilicus
• B. Nose to knee joint
• C. Ear lobe to umbilicus
• D. Ear lobe to knee joint
Ans: C
• Feeding tube length is measured by following the normal route for
the tube (Nasal ala → Ear lobe → Epigastrium).

• Distance between the nasal ala and ear lobe is almost equal to the
distance between the epigastrium and umbilicus, the length can be
measured from ear lobe to umbilicus.
• Q53. After RTA, a patient is in deep coma for last 13 days. Which of
the following is the most suitable route for the administration of
protein and calories?

• A. Nasogastric tube feeding

• B. Jejunostomy tube feeding
• C. Gastrostomy tube feeding
• D. Central venous hyperalimentation
Ans: B
• NG feeding or feeding through a gastrostomy tube may lead to
vomiting and aspiration in a patient who is in coma.
• This can be avoided by using a nasoenteric tube with the tip placed in
jejunum under fluoroscopic guidance or endoscopic control.

• Unless the GI tract is non functional, its use for nutritional support is
preferable as compared to TPN.
• Q54. Which of the following is the best vein for total parenteral
nutrition?

• A. Subclavian vein
• B. Brachial vein
• C. Femoral vein
• D. Saphenous vein
Ans: A
• Preferred site for central vein infusion: Subclavian vein

• Preferred access site for TPN: Subclavian > Jugular > Femoral
TPN Formulations
Solution with Lipids ( 3 – in – 1 ) Solution with Lipids (2 – in – 1)
60/20/20 75/25

Calories from dextrose: 60% Calories from dextrose: 75%

Calories from amino acids: 20% Calories from amino acids: 25%
Calories from lipids: 20%
• Q55. Which of the following is wrong about the shown blood
product?

• A. Stored at - 18° temperature

• B. Volume is 50 ml
• C. 1 unit increases the count by 5000 – 10000
• D. ABO compatibility is not necessary
Ans: A
Shown blood product is Platelet
• Volume: 50ml
• Platelets are the only blood products which are stored at room temperature, 20
– 20 °C (survival is 4 – 5 days)
• 1 unit of platelet increases the count by 5000 – 10000.
• Transfused platelets generally survive for 2-7 days following transfusion.
• ABO compatibility is desirable but not necessary.
• Blood platelets in stored blood are non-functional after 24 hours.

• The threshold for prophylactic platelet transfusion is 10,000/μL

• For invasive procedures, 50,000/μL platelets is the usual target level
• Platelet count should be 1,00,000/μL before accepting the patient for surgery.
• Q56. In a Covid positive patient, who was symptomatic and
recovered at home without hospital admission, elective surgery can
be planned after;

• A. 4 weeks
• B. 6 weeks
• C. 8 weeks
• D. 12 weeks
Ans: B
• Timing for elective surgery after recovery from COVID-19 uses both
symptom & severity based categories.
Wait times from the date of COVID-19 diagnosis to surgery as;
4 weeks For an asymptomatic patient or recovery from only mild,
non-respiratory symptoms
6 weeks For a symptomatic patient who did not require
hospitalization
8 – 10 weeks For a symptomatic patient who is diabetic,
immunocompromised or hospitalized
12 weeks For a patient admitted to ICU due to COVID-19 infection
• Q57. A 13 year old boy is admitted in emergency department after
perineal injury. After injury, patient did not pass the urine. O/E,
blood was present at the meatus and bladder was palpable. What is
the next line of management?

• A. Foley’s catheter insertion

• B. Suprapubic aspiration
• C. Wait and watch
• D. Wait for the bladder to fill and urge to urinate
Ans: B
• Clinical scenario suggests urethral injury. Next best step is suprapubic
cystostomy (Suprapubic aspiration)
• Q58. A young man is presented to emergency after H/O RTA. O/E he
had subcutaneous emphysema, absence of air entry on the right
side of hemithorax and hypotension. What is the next step of
management?

• A. Plan for intubation

• B. Fluid resuscitation with wide bore needle
• C. Positive pressure ventilation
• D. Needle decompression in 5th Intercoastal space
Ans: D
• Clinical scenario suggests tension pneumothorax.

• Preferred location for needle decompression is 5th ICS in the anterior

axillary line in adults.

• Tension pneumothorax and simple pneumothorax have similar signs,

symptoms and examination findings, but hypotension qualifies the
pneumothorax as tension pneumothorax.
• Q59. What is the sequence of abdominal examination?

• A. Inspection – Palpation – Percussion – Auscultation

• B. Inspection – Percussion – Palpation – Auscultation
• C. Auscultation – Palpation – Percussion - Inspection
• D. Inspection – Auscultation – Percussion – Palpation
Ans: D
• Q60. A 40 year old female presented with fatigue, dyspnea,
dizziness. O/E, her face appears to be pale. Which next investigation
will give more clarity about her condition?

• A. LFT
• B. CBC
• C. Chest X-ray
• D. ECG
Ans: B
PICKLE
• Pallor
• Icterus
• Cyanosis, Clubbing
• Koilonychia
• Lymphadenopathy
• Edema
• Q61. Physical examination in a patient is performed suspecting
abnormality in cardiovascular system. Which of the following is not
associated with pathology in the heart?

• A. Radio-radial delay
• B. Water hammer pulse
• C. Fluid thrill test
• D. Hepatojugular reflux
Ans: C
• Capillary Refill Time: < 2 sec is normal

• Palpate radial pulse (of 1 wrist) – Then both radial palpation to assess
Radio-radial delay – seen in coarctation of aorta

• Hold wrist and raise the arm: Check for COLLAPSING PULSE/water
hammer pulse/Corrigan’s pulse: seen in aortic regurgitation

• Palpate brachial pulse

• Auscultate Carotid artery to check any bruits – ask the patient to hold
breath

• Check Carotid pulse: Assess character and volume of the carotid pulse

• Ask patient to turn his head towards left: assess Jugular venous pressure at
45°
↓
• Assess for Hepatojugular reflux: palpate over Liver (observe for a rise in
JVP (If sustained rise >4cm = Positive result)
Schamroth’s Window Test: Lost with clubbing
• Q62. You are going on the morning round with senior consultant. You are
being asked to visit a particular patient for the general examination.
Which of the following should be the first to start with?

a. Establish a good communication with the patient

b. Confirm the identity of patient

c. Introduce yourself and explain examination

d. Take consent
Ans: B
• Q63. A 25 year old male is presented to OPD with complains of dry cough
for last 8 days. He tried antibiotics with cough syrup but no improvement.
Sometimes there is tightness in chest. On auscultation, there is no
wheezing or murmur sound. Chest X-ray and ECG are found to be normal.
What is the next line of management?

• A. Change antibiotics and cough syrup

• B. Increase the dose of cough syrup
• C. Levocetirizine + Montelukast + Syrup Dextromethorphan
• D. Gargle with hot water
Ans: C
• Q64. A boy is brought to hospital after H/O RTA where a bike ran
over his right foot. O/E, there is severe tenderness, swelling and he
is not able to keep his foot on the floor. There is no fracture found in
the X-ray foot. What is the next line of management?

• A. Apply a cast around the foot for 2 months

• B. No cast, only analgesics
• C. Immobilize + Tab Serratiopeptidase BD + Hot water fomentation +
keep the limb elevated
• D. Hospitalize the patient and keep under observation for 3 days
Ans: C
• Q65. A child presents with problem in walking, seizures and inappropriate
laughter. Her IQ is not appropriate as per her age. Which abnormality can
cause her symptoms?

• A. Deletion on paternal chromosome 15

• B. Deletion on maternal chromosome 15
• C. Trisomy of 21st chromosome
• D. Fragile X syndrome
Ans: B
• Genomic Imprinting:
PRADER WILLI SYNDROME ANGELMAN SYNDROME

Deletion of paternal Deletion of maternal

chromosome 15 chromosome 15

UPD of maternal chromosome 15 UPD of paternal chromosome 15

Presence of Mental retardation, Presence of mental retardation,

obesity, hypogonadism and seizures, ataxia and inappropriate
hypotonia behaviours (HAPPY PUPPET)
• Q66. A 25 year old woman presents to your clinic because of trouble with
her vision. Physical examination reveals a very tall, thin woman with long
and thin fingers. Examining her eyes reveals the lens of her eye to be in
the anterior chamber. Lab investigations show normal levels of
methionine and cystothionine. Which of the following is the most likely
cause og this patient’s signs and symptoms?

• A. Decreased level of Vitamin D

• B. Abnormal copper metabolism
• C. Defective synthesis of fibrillin
• D. Defective synthesis of collagen type I
Ans: C
• Clinical case depicts MARFAN SYNDROME, that results from defective
synthesis of fibrillin.
• It is an AD disorder
• Q67. A 35 year old man gets burn injury to his hands. Over few
weeks, the burnt skin heals without the need for skin grafting. What
is the most critical factor responsible for rapid healing in this case?

• A. Minimal edema and erythema

• B. Granulation tissue
• C. Underlying connective tissue
• D. Remnant skin appendages
Ans: D
• Skin has epidermis and dermis layers.

• Epidermis which is the most superficial layer of skin constantly

replaced from the basal layer and the dermis which is thicker than
epidermis and contains adnexal structures.

• Adnexal structures contain epithelial cells which can proliferate and

heal a partial thickness wound by epithelialization .
• Q68. Histologic sections of lung tissue from 65 year old woman, with
congestive heart failure and progressive breathing problems reveal
numerous hemosiderin laden cells within the alveoli. Which of the
following is the cell of origin of these heart failure cells?

• A. Lymphocytes
• B. Pneumocytes
• C. Macrophages
• D. Endothelial cells
Ans: C
• In the lung, alveolar macrophages can phagocytose the RBCs that
accumulate in alveoli in individuals with congestive heart failure.

• These cells contain hemosiderin and referred to as HEART FAILURE

CELLS
• Q69. Hypertrophy is increase in size of a cell in response to stress.
Which of the following does not represent the example of smooth
muscle hypertrophy as an adaptive response to the relevant
situation?

• A. Small intestine in intestinal obstruction

• B. Urinary bladder in urine outflow obstruction
• C. Triceps in body builders
• D. None
Ans: C
• Triceps enlargement is an example of skeletal muscle hypertrophy
(not smooth muscle)
• Q70. Asymptomatic hepatitis B is common in 2-3% normal
population, but there is increased risk of transmission into
hepatocellular carcinoma. What is the reason?

• A. High level of transaminase

• B. High rate of proliferation of heaptocytes
• C. Inability to induce inflammation to remove the organism
• D. Integration of viral DNA with host DNA
Ans: D
• DNA of the HBV integrates randomly into hepatocyte chromosomes
and acts as a non selective insertional mutagenic agent.

• Integration of HBV DNA into the host genome occurs in 90% of HBV
related HCC and has been postulated as a early event in chronic viral
infection.
• Q71. Few months after the open abdominal surgery, a patient
presented with the formation of scar as shown in photo. This
happens due to:

• A. Excess granulation tissue

• B. Excess Collagen
• C. Less granulation tissue
• D. Less collagen
Ans: B
• Hypertrophic scar and Keloid formation are because of excessive
collagen.

• Shown picture is keloid

• Q72. A urosurgeon has successfully performed a testicular biopsy
and handed over the specimen to the attending nurse. Sister asks
you how to send the specimen to the pathologist. What fluid would
you tell the sister to put the specimen in?

• A. 10% formalin
• B. 95% ethanol
• C. Bouin’s solution
• D. Zenker’s solution
Ans: C
Bouin’s is a noncoagulative picrate solution which is routinely
utilized to fix testicular biopsies because it preserves nuclear
detail.

Due to concern that common fixatives, such as formalin, may

distort the architecture of testicular tissues, Bouin solution has
traditionally been the recommended fixative for testis biopsy
specimens. Bouin solution is a preparation of 5% acetic acid,
9% formaldehyde, and 1.5% picric acid in aqueous solution
 IMPORTANT FIXATIVES
Routine Fixative 10% buffered normal formalin (MC used)
Adrenal medulla Orth’s fluid
Bone marrow aspiration Helly’s fluid
Bone marrow biopsy Zenker’s fluid & B-5 (Give excellent nuclear detail, best for fixation of
hematopoietic & reticuloendothelial tissues)
Karyotyping fixatives Carnoy’s
Cytoplasmic fixatives Champy’s fluid
Cell blocks Bouin’s fluid
Nuclear Fixatives - Carnoy’s fluid
- Clarke’s fluid
Brain tissue Formalin ammonium bromide
Pap’s smear 95% ethanol
Gastrointestinal biopsies Bouin’s fluid
Testis and ovary Susa’s fluid
• Q73. Kinky hair disease is a disorder where an affected child has peculiar
white stubby hair, does not grow, brain degeneration is seen and dies by
age of two years. Mrs A is hesitant about having children because her
two sisters had sons who had died from kinky hair disease. Her mother’s
brother also died of the same condition. Which of the following is the
possible mode of inheritance in her family?

• A. X-linked recessive
• B. X-linked dominant
• C. Autosomal recessive
• D. Autosomal dominant
Ans: A
• Given disease is manifesting only in males, therefor it is sex linked disease.

• Females are not affected, so they must be carriers. This is a classical inheritance
feature of X-linked recessive disorder.

• Male is having XY, i.e. only one X chromosome. So, even if one mutant allele is
present on X-chromosome, it will manifest (whether recessive or dominant)
• Females are XX, so if gene is mutated in X-chromosome, female will be
phenotypically normal and genotypically carrier, if inheritance is recessive but
female will suffer from disease, if it is X-linked dominant.

• There is no sex predilection in autosomal dominant or recessive disorders.

• Q74. A 35 year old female is suffering from a motor disorder of
esophagus, where she has substernal chest pain and dysphagia due
to repetitive simultaneous non peristaltic contractions. Radiological
appearance on barium swallow is given here. Which of the following
is an incorrect statement related to her condition?

• A. She is suffering from diffuse esophageal spasm

• B. Manometry is the gold standard test
• C. Presence of primary contractions
• D. Mainstay of treatment is pharmacological.
Ans: C
• As per clinical condition: it is Diffuse Esophageal Spasm

• Barium swallow: Corkscrew esophagus, Curling Esophagus,

pseudodiverticulosis.

• It is due to tertiary contractions.

• Q75. A medical examination of a student reveals absence of cardiac
sounds on left side of the chest but surprisingly the normal heart heart
beat on the right side of the chest. The liver edge can be palpated on the
left but not the right side of the abdomen. He also gives history of
bronchiectasis and sinusitis. Which of the following should be suspected?

• A. Down’s syndrome
• B. Kawasaki disease
• C. Kartagener syndrome
• D. Marfan syndrome
Ans: C
• Isolated inversion of the heart (dextrocardia) is almost always associated
with cardiac defects that may include transposition of the atria and
transposition of great arteries.

• However, dextrocardia as part of situs inversus totalis, with reversal of the

thoracic and abdominal organs, is usually associated with a physiologically
normal heart.

• Cluster of situs inversus, sinusitis and bronchiectasis is called KARTAGENER

SYNDROME, which is caused by defective ciliary function.
• Q76. Patient with bleeding due to platelet function defects has
which of the following features?

• A. Normal platelet count & normal bleeding time

• B. Normal platelet count & Increased bleeding time
• C. Decreased platelet count & Increased bleeding time
• D. None
Ans: B
• As per the question, there is platelet function defect.
• It means that the platelet count is normal with a problem in the
functioning of platelets.

Bleeding Time: represents the time taken for a standardized skin

puncture to stop bleeding and it gives an in vivo assessment of platelet
response to limited vascular injury.
• The value varies from 2-9 minutes.
• It is abnormal when there is a defect in platelet number or function.
• Q77. During the surgery of patella fracture, a torniquet was applied over
thigh. Junior doctor forgot to remove the torniquet after completion of
surgery. Patient is shifted to ward. After 6 hours of surgery, patient
complained of severe pain in thigh. Nurse found that there was a
torniquet applied. She removed it and patient went into coma in next few
hours. What can be the reason?

• A. Toxic Reaction due to quick release of toxins when tourniquet is

loosened
• B. Embolism & DVT
• C. Rhabdomyolysis and Septic shock
• D. All
Ans: D
• A cascade of medical events occurs when a tourniquet is applied with enough
pressure to stop arterial flow.
• When arterial flow is stopped it also means that return blood flow is stopped.
This has many deleterious effects, directly related to the amount of pressure
and length of time it is used, underneath and distal to the tourniquet:

a.Nutrients do not get down to the cells.

b.Oxygen does not get down to the cells.
c. Waste products of metabolism are not removed.
d.Concentrations of the arterial and venous blood pool, diluting concentrations
of each. Diluted, passive osmosis cannot get the nutrients into the cells or the
toxic waste products out.
a. Toxic Reaction due to quick release of toxins when tourniquet is loosened providing less
tendency to go into shock, Vs. Slow release due to open circulation when toxins are released
in low doses over time.
b. Amputation necessary due to cell death.
c. Embolism and Deep Venous Thrombosis potentially life threatening.
d. Tourniquet paralysis syndrome due to Nerve damage resulting in limb paralysis, partial or
complete, paresthesia - pain, loss of sensation, etc.
e. Post Tourniquet Syndrome.
f. Compartment Compression Syndrome.
g. Pressure sores, skin damage.
h. Hyperthermia especially when more than one is used o Sepsis.
i. Rhabdomyolysis - metabolic breakdown of cells.
j. Tachycardia, Pyrexia, Pain, tenderness, edema and hemorrhage, Dark urine and oliguria.
k. Increased Cerebral Blood Flow which can be dangerous in persons with increased
intracranial pressures.
l. Tourniquet Pain syndrome
• Q78. Three tests are shown for proteins, sugar and ketones. Which
of the following will be positive in starvation state in urine?

• A. Only 1
• B. Only 2
• C. 2 and 3
• D. 1 and 2

1 2 3
 Ans: B
• Ketogenesis is associated with excessive fatty acid oxidation, which
occurs most notably in starvation and diabetes (type I DM).

• Hyperketonemia (higher level of ketone bodies in blood) or Ketonuria

(higher level of ketone bodies in urine) is called as KETOSIS. It occurs
in starvation.

• Ketone bodies will be positive in starvation in patient’s urine.

• Basic form of ketosis occurs in starvation and involves depletion of

available carbohydrate coupled with mobilization of FFAs.
• Ketone bodies are products of incomplete fat metabolism.
• Three ketone bodies excreted in urine are:
1. Acetoacetic acid (20%)
2. Acetone (2%)
3. Beta-hydroxybutyric acid (78%)
TESTS FOR KETONURIA

ROTHERA’S TEST PURPLE COLOURED RING – formed by combination of Ketone bodies

(acetone & acetoacetic acid) with alkaline solution of sodium
nitroprusside

GERHARDT’S TEST BROWNISH RED COLOUR – By adding Ferric chloride to urine

REAGENT STRIP TEST PURPLE – stripos coated with alakaline sodium nitroprusside dipped in
urine and it turns purple
BIURET’S TEST FOR PROTEINS ROTHERA’S TEST FOR KETONE BODIES BENEDICTS TEST FOR REDUCING
SUGAR
• Q79. In spite of taking fat free carbohydrate rich diet, a person
continues to grow obese. Which of the following lipoprotein is likely
to be elevated in his blood?

• A. VLDL
• B. LDL
• C. HDL
• D. Chylomicrons
Ans: A
• As the person is taking fat free diet, there is no tryglyceride In diet,
i.e. no exogenous lipid. So chylomicrons level will be decreased as
they carry exogenous TGs.

• So, the cause of obesity in this patient is endogenous synthesis of

lipids. In obesity, TGs are deposited in adipose tissues. the major
carrier of endogenous TGs is VLDL.

• So this person is likely to have elevated VLDL.

Q80. A patient presented with complaints of some abnormal deposits
in eyes and ear as shown below. Suspecting a metabolic disorder,
clinician did his X-ray spine and urine analysis. Findings are shown
below. Which enzyme deficiency can cause these symptoms?

a. Tyrosine Transaminase
b. Homogentisate oxidase
c. Phenylalanine hydroxylase
d. Hydroxyphenyl pyruvate hydroxylase
Ans: B

Enzyme deficiency and Metabolic disorders

Deficiency of Homogentisate oxidase - Alkaptonuria
Deficiency of Phenylalanine hydroxylase - Phenylketonuria
Deficiency of Hydroxyphenyl pyruvate hydroxylase – Neonatal
Tyrosenemia
Deficiency of fumarylacetoacetate hydroxylase – Tyrosenemia type I
(Hepatorenal syndrome)
Deficiency of Tyrosine Transaminase – Tyrosenemia type II (Richer-
Hanhart syndrome)
Q81. A 45 year old man presents to a clinic with complaints of
weight loss, frequent urination, increased thirst & appetite.
His father had similar symptoms who was on metformin for
last 7 years. Clinician wants to check his sugar level and lab
technician has collected his blood sample in the given tube.
This sample tube has one agent that ensures that further
breakdown of glucose will not happen, so that accurate level
of glucose can be estimated. Which of the following is a right
statement related to the scenario?

a. Potassium oxalate inhibits Enolase enzyme

b. It’s a plane tube which does not have any extra ingredients
c. Sodium fluoride inhibits Enolase enzyme
d. Sodium fluoride has no role
Answer: C
• Grey tube is used to collect the blood sample for sugar.
• It contains sodium fluoride and potassium oxalate.
• Sodium fluoride inhibits enolase enzyme, so that there won’t be
further degradation of glucose.
• Potassium oxalate is an anticoagulant.
• Q82. A 55 year old female presents with pain and swelling as shown in
photo. Sudden attacks of pain comes often in night. Her KFT investigation
shows Uric acid level 9.4 mg/dL and creatinine 0.9 mg/dL. Which of the
following can be associated with her condition?

• A. Disorder of Pyrimidine metabolism

• B. Disorder of Purine Metabolism
• C. Disorder of fatty acid synthesis
• D. Disorder of glucose metabolism
Answer: B
• Gout is a metabolic disorder associated with hyperuricemia.

• Primary gout is due to increased production of purine nucleotides.

• Purine nucleotides cannot be stored in the body, therefore increased

production is associated with increased catabolism with formation of
uric acid.
• Q83. A 9 year girl is presented to your clinic with complaints
of acute abdominal pain on and off with tingling sensation of
limbs. Her mother is informing that she used to be the fond
of eating paint from the wall of newly built house. Which
enzyme deficiency can cause these symptoms?

• A. Heme synthase
• B. ALA synthase
• C. ALA dehydratase
• D. Coproporphyrinogen synthase
Answer : C
• ALA dehydratase is a ZINC containing enzyme and is sensitive to
inhibition by lead (present in the paints).
• High levels of lead can affect heme metabolism by combining with SH
groups in enzymes such as ferrochelatase and ALA dehydratase.
• Q84. A case of short bowel syndrome due to terminal
ileum resection, presents to your clinic with difficulty in
breathing, fatigue, diarrhea, nausea and loss of appetite.
On further examination, he has glossitis and tingling
sensation in his limbs. Which of the following deficiency
can cause these symptoms?

• A. Retinol
• B. Zinc
• C. Thiamine
• D. Cynocobalamine
Answer: D
• Function of terminal ileum: Reabsorption of Vitamin B12 and
hepatocirculation of bile salts

• Megaloblastic anemia can be due to folate deficiency and cobalamine

(Vit B12) deficiency.

• Cobalamine deficiency will cause neurological symptoms, as its

needed for myelination of nerves.
• Q85. A 35 year old lady presents with fatigue and tingling sensation
in both hands and legs. On examination, she is found to have a
fissured red tongue, lesions at angle of mouth and peripheral
neuropathy with a decreased RBC glutathione reductase activity.
What is the likely deficient vitamin?

• A. Vitamin B6
• B. Vitamin B12
• C. Vitamin B2
• D. Vitamin B1
Ans: C
RIBOFLAVIN (Vitamin B2) DEFICIENCY:

Clinical Manifestations:
• Cheilosis
• Glossitis
• Angular stomatitis
• Seborrheic dermatitis
• Keratitis, conjunctivitis, corneal vacularization

• Decreased RBC glutathione reductase activity

• Lab Diagnosis of Riboflavin Deficiency can be made by determination
of RBC or urinary riboflavin concentrations or by measurement of
erythrocyte glutathione reductase activity, with and without added
FAD. - Harrison

Diagnosis of deficiency:
• Urinary excretion of < 10% of intake over 24 hours
• Measurement of the activation of erythrocyte glutathione reductase
by FAD added in vitro
• Q86. A 10 month old child was having vomiting after eating fruits,
but is of normal weight, he has been exclusively breast fed till now.
Doctor diagnosed him a case of fructose intolerance. Which enzyme
deficiency can be the reason for his symptoms?

• A. Hexokinase
• B. Fructokinase
• C. Aldolase B
• D. Glucose 6 phosphatase
Ans: C
• Absence of aldolase B, which cleaves fructose 1-phosphate, leads to
hereditary fructose intolerance.

• Treatment: Fructose free diet

• Q87. A 46 year old lady presented with bony pain. On physical
examination, hepatosplenomegaly is found. On examination of
biopsy specimen from spleen, crumpled tissue paper appearance is
seen. Which of the following product is likely to have accumulated?

• A. Sulfatide
• B. Ganglioside
• C. Glucocerebroside
• D. Sphingomyelin
Ans: C
• Clinical history of bone pain and hepatosplenomegaly with CRUMPLED
TISSUE PAPER APPEARANCE ON BIOPSY is highly suggestive of GAUCHER’S
DISEASE. (Due to deficiency of Beta-glucosidase (GLUCOCEREBROSIDASE).
• Glucocerebroside is accumulated in brain.

HISTOPATHOLOGY:
• The cerebrocide laden cells are large & have eccentric nuclei, the
cytoplasm appears like crumpled silk or tissue paper (GAUCHER’S CELLS)
• Q88. Which incision is indicated by number 8 in the given image?

• A. Lanz
• B. Rutherford Morrison
• C. Kocher
• D. Battle
Ans: B
• Q89. Which size of surgical blade is shown here?

• A. 10
• B. 11
• C. 15
• D. 23
Ans: B
• Q90. Name the type of suturing performed here;

• A. Vertical mattress
• B. Horizontal mattress
• C. Surgical knot
• D. Subcuticular interrupted
Ans: B
HORIZONTAL MATTRESS SUTURING VERTICAL MATTRESS SUTURING
• Q91. In a case of carcinoma Gallbladder, stage T2a, a surgeon
planned for extended cholecystectomy. Which of the following
structures will be removed during the surgery?

• A. Gallbladder
• B. Gallbladder with Liver segments V + IVa
• C. Gallbladder with Liver segments V + IVb
• D. Gallbladder with extended right hepatectomy
Ans: C
For stage T2a: Extended cholecystectomy should be performed

Carcinoma Gallbladder

• IA – T1a – Lap Cholecystectomy

• IB – IIIB – Extended Cholecystectomy
• IVA – Extended Cholecystectomy + Extended Right Hepatectomy
• IVB – Palliation Chemotherapy ( Gemcitabine + Cisplatin)

• Extended Cholecystectomy: Segment IVb + V + Gallbladder

LIVER SEGMENTS
• Right Anterior Sector: V, VIII
• Right Posterior Sector: VI, VII
• Left Anterior Sector: III, IV
• Left Posterior Sector: only II
Right Hemi-Hepatectomy: V, VI, VII, VIII
Left Hemi-Hepatectomy: II, III, IV

Extended Hepatectomy/Trisegmentectomy:
Extended RHT: V-VIII + IVa and IVb
Extended LHT: II-IV + V and VIII
• Q92. A 48 year old female presents with symptoms of acute
cholecystitis. Symptoms are controlled with medical management.
On USG, there is a solitary gallstone of size 1.5cm. Which of the
following is the next most appropriate step in the management of
this patient?

• A. I/V antibiotics
• B. Regular follow up
• C. Open cholecystectomy immediately
• D. Laparoscopy cholecystectomy immediately
Ans: D
• Composition of gallstone: CRYSTALLINE CHOLESTEROL MONOHYDRATE

• Types of Gallstones?

• 3 Mandatory factors for gallstone formation?

• 4. Radiolucent/Radio-opaque?

• 5. differentiate biliary colic and acute cholecystitis?

• Q93. A 52 year old female presents with RUQ abdominal pain. She has
history of jaundice in past. Examination and Lab Investigations reveal
chronic calculous cholecystitis. Kidney functions tests and Liver function
tests are within normal range. On USG examination, common bile duct is
not dilated. Which of the following is the procedure of choice for this
patient?

• A. Laparoscopic Cholecystectomy
• B. Open Cholecystectomy with CBD exploration
• C. Laparoscopic Cholecystectomy followed by ERCP
• D. ERCP followed by Laparoscopic Cholecystectomy
Ans: A
Q94. Which of the following is a wrong statement related to the shown
anomaly here?

• A. A dangerous anomaly in arterial supply of GB

• B. An anomaly of right hepatic artery
• C. A tortuous course of Cystic duct
• D. It can cause problems during cholecystectomy
Ans: C
• Shown anomaly is MOYNIHAN’S HUMP/CATERPILLAR TURN.
• It is most dangerous anomaly in arterial supply of GB, where in, right
hepatic artery takes tortuous course on the front of origin of cystic
duct.
• Ligation of cystic artery is a procedural prerequisite during any
surgical procedure involving gallbladder.
• In some cases, right hepatic artery may come very close to gallbladder
& cystic duct in the form of “Caterpillar hump or Moynihan hump’’.
• If such a hump is present, the cystic artery inturn is very short.
• In this situation right hepatic artery is liable to be mistakenly
identified as cystic artery and it will be ligated prior to
Cholecystectomy.
• So, right functional lobe of liver goes for necrosis.
• Q95. Stone formation in gallbladder is enhanced by all except;

• A. Ileal resection
• B. Cholestyramine therapy
• C. Vagal Stimulation
• D. High calorie and cholesterol diet
Ans: C
• Vagal stimulation increases GB motility and thus prevents stone
formation.
• Q96. A 45 year old patient has undergone an open cholecystectomy. The
procedure was reported as uneventful by the operating surgeon. She has
100 ml of bile output from the drain kept in the gallbladder bed on the
first post operative day. On examination she is afebrile and anicteric. The
abdomen is soft and bowel sounds are normally heard. As an attending
physician, what should be your best advice?

• A. Instruct for an urgent ERCP and biliary stenting

• B. Instruct for an urgent HIDA scan
• C. Urgent Laparotomy
• D. Clinical Observation
Ans: D
• 100 ml of bile output from the patient on post operative day 1,
without any other abnormality is of no clinical significance.

• So it doesn’t warrant any action from the surgeon.

• But passing 100 mL of bile continues for 5-6 days, then it denotes bile
duct injury. It needs proper intervention.
• Q97. A 53 year old woman presented with history of recurrent episodes
of RUQ abdominal pain for last one year. She presented to casualty with
history of jaundice and fever for 4 days. On examination, the patient
appeared toxic and had a BP of 90/60 mmHg. She was started on I/V
antibiotics. USG of abdomen showed presence of stones in common bile
duct. Which of the following would be the better treatment option for
her?

• A. Lithotripsy
• B. Open surgery and bile duct stone extraction
• C. Laparoscopic Cholecystectomy
• D. ERCP and bile duct stone extraction
Ans: D
• Q98. Which of the following is a wrong match?

• A. TIPS – A shunt between portal vein and hepatic vein

• B. Pringle Manoeuvre – Clamping of hepatic artery
• C. Sengstaken tube – To stop bleeding from varices
• D. Linton’s shunt – Non selective shunt
Ans: B
• PRINGLE MANEOUVER: Clamping of hepatoduodenal Ligament
PRINGLE’S MANEOUVER – Total occlusion of
inflow
Portal triad: Located in free edge of hepato-duodenal ligament
Apply a clamp over FORAMEN OF WINSLOW & control bleeding
by occlusion of portal vein > hepatic vein
- It doesn’t control bleeding from IVC and hepatic vein
• Q99. During Liver Transplantation, which of the following is
anastomosed in last?

• A. Portal vein
• B. Bile duct
• C. Hepatic artery
• D. Inferior Vena Cava
 Ans: B
5 Sequential Anastomosis for Whole Liver Orthotopic
Transplantation
1. Suprahepatic IVC
2. Infrahepatic IVC
3. Portal Vein
4. Hepatic artery
5. Bile duct
SIP-HB

Piggiback Tx: Original IVC is not disturbed

Conventional Tx: Original IVC is disturbed

During surgery, patient may get REPERFUSION SYNDROME. This occurs after the anastomosis of
portal vein
• Q100. In a patient with the burn wound extending into the
superficial epidermis without involving the dermis would present
with all of the following except;

• A. Anaesthesia at the site of burn

• B. Healing of the wound spontaneously without sacr formation
• C. Erythematous
• D. Painful
Ans: A
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