Q-201. Cardiac output measured by thermo-dilution technique is unreliable in all of the following situations except
a) Ventricular septal defect
b) Tricuspid regurgitation
c) Low cardiac output
d) Pulmonary regurgitation
Answer: None
Explanation:
Cardiac output measured by thermo-dilution technique is unreliable in:
Pulmonary valve insufficiency
Tricuspid regurgitation
Low cardiac output status
Right to left shunt
Left to right shunt
Q-202. All of the following heart sounds occur shortly after S2 except
a) Opening snap
b) Pericardial knock
c) Ejection click
d) Tumor plop
Answer: Ejection click
Explanation:
Heart sounds occur shortly after S1:
Ejection click
Heart sounds occur shortly after S2:
Opening snap
Pericardial knock
Tumor plop
Third heart sound
Shortly before S1:
Fourth heart sound
Between S1 and S2:
Mid-systolic click
Q-203. An early systolic murmur may be caused by all of the following except
a) Small ventricular septal defect
b) Papillary muscle dysfunction
c) Tricuspid regurgitation
d) Aortic stenosis
Answer: Aortic stenosis
Explanation:
Systolic Murmurs:
Early Systolic murmurs:
VSD- Large VSD with pulmonary hypertension and small VSD
Tricuspid regurgitation in absence of pulmonary hypertension
Mitral regurgitation in non-compliant left atrium
Mid systolic murmur:
Aortic- Aortic stenosis, Coarctation, Aneurysm, PDA and High output states
Pulmonary- Pulmonary stenosis, pulmonary hypertension, pulmonary artery dilatation, ASD and High output states
Pansystolic or Holosystolic murmur:
VSD
Tricuspid regurgitation
Mitral regurgitation
Aortico-pulmonary shunt
Important point:
Conditions producing acute mitral regurgitation- Rupture of chordae tendinae, papillary muscle dysfunction and infective endocarditis
Q-204. Exercise testing is absolutely contraindicated in which one of the following
a) One week following myocardial infarction
b) Unstable angina
c) Aortic stenosis
d) Peripheral vascular disease
Answer: Aortic stenosis
Explanation:
Contra-indications of exercise stress testing:
Acute MI (< 4-5 days) Rest angina (< 48 hours) Acute myocarditis Severe aortic stenosis Active infective endocarditis Un-controlled heart failure Unstable rhythm Q-205. The most common cause of tricuspid regurgitations is secondary to a) Rheumatoid heart disease b) Dilatation of right ventricle c) Coronary artery disease d) Endocarditis due to intravenous drug abuse Answer: Dilatation of right ventricle Explanation: Most common cause of TR is functional and secondary to marked dilatation of right ventricle and tricuspid annulus. Q-206. Which of the heart valve is most likely to be involved by infective endocarditis following a septic abortion? a) Aortic Valve b) Tricuspid valve c) Pulmonary valve d) Mitral valve Answer: Tricuspid valve Explanation: Infective endocarditis involving right heart valves: Intravenous drug abusers Septic abortion Staphylococcus aureus may cause right-sided endocarditis with large vegetation and it may follow septic abortion. Q-207. Osler’s nodes are typically seen in which one of the following? a) Chronic Candida endocarditis b) Acute staphylococcal endocarditis c) Pseudomonas endocarditis d) Libman sack’s endocarditis Answer: Acute staphylococcal endocarditis Explanation: Peripheral signs of endocarditis: Roth’s spots: Oval- shaped, white- centered hemorrhages present on the retina Osler’s nodes: Painful, erythematous nodules most commonly found on the pads of the fingers and toes Janeway lesions: Non-tender, erythematous and nodular lesions most commonly found on the palms and soles Splinter hemorrhages: Small, linear hemorrhages under the nails Important point: Staphylococcus aureus is leading cause of infective endocarditis; and gram negative organism and fungi account for small percentage. Q-208. Troponin-T is preferable to CPK-MB in the diagnosis of acute myocardial infarction (MI) in all of the following situations except a) Bedside diagnosis of MI b) Postoperatively (after CABG) c) Re-infarction after 4 days d) Small infarcts Answer: Re-infarction after 4 days Explanation: Troponin is more sensitive and specific than CK-MB. Circulating levels of Troponin may remain elevated for 5-7 days or longer and therefore are generally not useful for evaluating suspected early re-infarction. Elevated CK-MB generally normalizes within 24 hours, thus being more helpful for evaluation of re-infarction. Q-209. During cardiopulmonary resuscitation, intravenous calcium gluconate is indicated under all of the following circumstances except a) After 1 minute of arrest routinely b) Hypo-calcemia c) Calcium channel blockers toxicity d) Electromechanical dissociation Answer: After 1 minute of arrest routinely Explanation: Indications of intravenous calcium gluconate administration during cardiopulmonary resuscitation: Known hypo-calcemia Toxic dose of calcium channel blockers Acute hypokalemia triggering event for resistant ventricular fibrillation (?) Electromechanical dissociation Q-210. A post-operative cardiac surgical patient developed sudden hypotension; raised central venous pressure and Pulsus paradoxus at the 4th post operative hour. The most probable diagnosis is a) Excessive mediastinal bleeding b) Ventricular dysfunction c) Congestive cardiac failure d) Cardiac tamponade Answer: Cardiac tamponade Explanation: Acute cardiac tamponade: Elevated intra-pericardial pressure > 15 mm Hg
Signs and symptoms:
Pain in inflammatory cases or painless in neoplastic or uremic effusion
Dyspnea and cough
A pericardial friction rub
Tachycardia and tachypnea
Pulsus paradoxus (Also found in obstructive lung disease and asthma) and a relatively preserved systolic pressure
Elevated central venous pressure
Investigation:
Echocardiography is primary method for demonstrating pericardial effusion.
ECG: Non-specific T wave changes and low QRS voltage X-ray chest: Enlarged cardiac silhouette with globular configuration
Treatment:
Urgent paracentesis when tamponade present
Q-211. The blood gas parameters pH 7.58, pCO2 23 mm Hg, pO2 300 mmHg and oxygen saturation 60 % are most consistent with
a) Carbon monoxide poisoning
b) Ventilatory malfunction
c) Voluntary malfunction
d) Methyl alcohol poisoning
Answer: Ventilatory malfunction (?)
Explanation:
Carbon monoxide poisoning- Acidic pH
Methyl alcohol poisoning- Acidic pH
Q-212. The diffusion capacity of lung (DLCO) is decrease in all of the following conditions except
a) Interstitial lung disease
b) Goodpasture’s syndrome
c) Emphysema
d) Primary pulmonary hypertension
Answer: Goodpasture’s syndrome
Explanation:
This test is used to estimate the transfer of oxygen from the alveoli in lungs to bloodstream.
The diffusing capacity (DL) of oxygen is technically very difficult to measure, and the test actually measures the diffusing capacity of carbon monoxide (DLCO) which provides a valid estimate of the oxygen diffusion.
Lowered the diffusion capacity of lung:
Interstitial lung disease
Emphysema
Pulmonary hypertension/ pulmonary emboli
Elevated the diffusion capacity of lung:
Goodpasture’s syndrome
Q-213. A 55 year old man who has been on bed rest for the past 10 days complains of breathlessness and chest pain. The chest X-ray is normal. The next investigation should be
a) Lung Ventilation-perfusion Scan
b) Pulmonary Arteriography
c) Pulmonary Venous Angiography
d) Echocardiography
Answer: Lung Ventilation-perfusion Scan
Explanation:
Pulmonary venous thrombo-embolism:
Clinical features:
Dyspnea, chest pain, hemoptysis and syncope
Laboratory findings:
ECG: Sinus tachycardia and non-specific ST and T wave changes
ABG: Respiratory acidosis and the arterial Po2 and the alveolar-arterial oxygen difference usually abnormal
D-dimer: Increased level of plasma D-dimer
Chest X-ray:
May be normal or
Atelectasis, parenchymal infiltration and pleural effusion
Ventilation-perfusion lung Scan
Helical CT pulmonary angiography
Pulmonary angiography-Reference standard for the diagnosis of PE
Q-214. Diagnostic features of allergic bronchopulmonary aspergillosis (ABPA) include all of the following except
a) Changing pulmonary infiltrates
b) Peripheral eosinophilia
c) Serum precipitins against aspergillosis fumigants
d) Occurrence in patients with old cavitatory lesions
Answer: Occurrence in patients with old cavitatory lesions
Explanation:
Primary criteria for diagnosis of allergic bronchopulmonary aspergillosis (ABPA):
A clinical history of asthma
Peripheral eosinophilia
Immediate skin reactivity to Aspergillus antigen
Precipitating antibodies to Aspergillus antigen
Elevated serum IgE levels
Pulmonary infiltrate
Central bronchiectasis
Secondary diagnostic criteria:
Aspergillus in sputum
A history of brown flecked sputum
Late skin reactivity to Aspergillus antigen
Q-215. Which one of the following conditions may lead to exudative pleural effusion?
a) Cirrhosis
b) Nephrotic syndrome
c) Congestive heart failure
d) Bronchogenic carcinoma
Answer: Bronchogenic carcinoma
Explanation:
Causes of pleural effusion:
Transudative pleural effusion:
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Peritoneal dialysis
Myxedema
Constrictive pericarditis
SVC obstruction
Exudative pleural effusion:
Cancer
Pneumonia
Tuberculosis
Connective tissue diseases
Viral infection
Meig’s syndrome
Pancreatic disease
Uremia
Chylothorax
Drug reaction
Post MI syndrome
Q-216. Pulmonary hypertension may occur in all of the following conditions except
a) Toxic oil syndrome
b) Progressive syndrome
c) Sickle cell anemia
d) Argemone Mexicana poisoning
Answer: Argemone Mexicana poisoning
Explanation:
Epidemic dropsy is a clinical state resulting from use of edible oils adulterated with Argemone Mexicana oil. Sanguinarine and dihydro-sanguinarine are two major toxic alkaloids of Argemone oil, which cause widespread capillary dilatation, proliferation and increased capillary permeability.
Leakage of the protein-rich plasma component into the extracellular compartment leads to the formation of edema.
Important point:
Pulmonary hypertension doesn’t occur in Argemone Mexicana poisoning.
Q-217. A 60 year old male presented to the emergency with breathlessness, facial swelling and dilated veins on the chest wall. The most common cause is
a) Thymoma
b) Lung cancer
c) Hodgkin’s lymphoma
d) Superior vena caval obstruction
Answer: Superior vena caval obstruction
Explanation:
Superior vena caval obstruction:
Dyspnea, dizziness, headache, visual disturbance or syncope
Bending over or lying down accentuates the symptoms.
Swelling of the neck, face and upper extremities
Dilated veins over upper chest and neck
Q-218. Which of the following hepatitis viruses have significant perinatal transmission?
a) Hepatitis E virus
b) Hepatitis C virus
c) Hepatitis B virus
d) Hepatitis A virus
Answer: Hepatitis B virus
Explanation:
Perinatal transmission in decreasing order:
Hepatitis B virus
Hepatitis D virus
Hepatitis C virus
Q-219. The syndrome of inappropriate anti-diuretic hormone is characterized by the following
a) Hypo-natremia and urine sodium excretion >20 meq/L
b) Hypernatremia and urine sodium excretion >20 meq/L
c) Hypo-natremia and Hyper-kalemia
d) Hypernatremia and Hypokalemia
Answer: Hypo-natremia and urine sodium excretion >20 meq/L
Explanation:
Clinical diagnosis of SIADH:
Hypo-natremia
Urine Na+ > 20 mEq/L
Decreased osmolality
Normal thyroid and adrenal function
Absence of heart, kidney or liver disease
Q-220. A 23- year old woman has experienced episodes of myalgias, pleural effusion, pericarditis and arthralgias without joint deformity over course of several years. The best laboratory screening lest to diagnose her disease would be
a) CD4 lymphocyte count
b) Erythrocyte sedimentation rate
c) Antinuclear antibody
d) Assay for thyroid hormones
Answer: Antinuclear antibody
Explanation:
Laboratory findings of SLE:
Antinuclear antibody test is sensitive but not specific to SLE. They are positive in virtually all patients with SLE.
Antibodies to ds-DNA and Sm are specific for SLE but not sensitive.
Decreased serum complement- A finding suggestive of disease activity and often retunes toward normal in remission.
Q-221. Disseminated intravascular coagulation (DIC) differs from thrombotic thrombocytopenic purpura (TTP). In this reference the DIC is most likely characterized by:
a) Significant numbers of schistocytes
b) A brisk reticulocytosis
c) Decreased coagulation factor levels
d) Significant thrombocytopenia
Answer: Decreased coagulation factor levels
Explanation:
Disseminated intravascular coagulation (DIC) is characterized by systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to micro-vascular thrombi in various organs and contributing to multiple organs dysfunction syndrome (MODS).
Consumption and subsequent exhaustion of coagulation proteins and platelets (from ongoing activation of coagulation) may induce severe bleeding, though micro-clot formation may occur in the absence of severe clotting factor depletion and bleeding.
In DIC, the levels of coagulation factors are decreased. Whereas in TTP, coagulation factor levels are normal.
Q-222. A 5 year old girl came with history of progressively increasing pallor since birth and hepato-splenomegaly which of the following is the most relevant test for achieving diagnosis
a) Hb electrophoresis
b) Peripheral smear examination
c) Osmotic fragility test
d) Bone marrow examination
Answer: Hb electrophoresis
Explanation:
Hemoglobin electrophoresis is the test of choice for diagnosing thalassemia.
Thalassemia minor:
Clinically insignificant
Microcytic anemia
Thalassemia intermedia:
Progressive and chronic hemolytic anemia
They survive into adult life.
Hepato-splenomegaly and bony deformities
Thalassemia major:
Affected child are normal at birth but after 6 months, when hemoglobin synthesis switches from hemoglobin F to HbA, develop severe anemia requiring transfusion.
Q-223. Elevated serum ferritin, serum iron and percent transferring saturation are most consistent with the diagnosis of
a) Iron deficiency anemia
b) Anemia of chronic disease
c) Hemochromatosis
d) Lead poisoning
Answer: Hemochromatosis
Explanation:
Complications of hemochromatosis:
Arthropathy
Cardiac enlargement, heart failure and conduction defect
Diabetes mellitus
Hypopituitarism, erectile dysfunction
Liver cirrhosis, portal hypertension, hepato-cellular carcinoma
Diagnosis of hemochromatosis:
Elevated plasma iron
More than 50 % transferrin saturation in men and 45 % in women
Elevated serum ferritin
Testing for HFE mutation
Treatment of hemochromatosis:
Avoid foods rich iron, alcohol, vitamin C etc
Weekly phlebotomies
Proton pump inhibitor-Reduces intestinal iron absorption
IV deferoxamine/ Oral deferasirox
Q-224. Bone marrow transplantation can be used as a treatment for all except
a) Osteo-petrosis
b) Adreno-leuko-dystrophy
c) Hurler’s syndrome
d) Hemochromatosis
Answer: Hemochromatosis
Explanation:
Treatment of hemochromatosis:
Avoid foods rich iron, alcohol, vitamin C etc
Weekly phlebotomies
Proton pump inhibitor-Reduces intestinal iron absorption
IV deferoxamine/ Oral deferasirox
Q-225. All of the following statement are true about sickle cell disease except
a) Patient may require frequent blood transfusions
b) Acute infection is the most common cause of mortality before 3 years of age
c) There is positive correlation between concentration of HbS and polymerization of HbS
d) Patient presents early in life before 6 months of age
Answer: Patient presents early in life before 6 months of age
Explanation:
Sickle cell anemia is an autosomal recessive disorder.
The rate of sickling is influenced by the concentration of hemoglobin S.
Hemoglobin F markedly retards sickling.
Sickle cell anemia is confirmed by hemoglobin electrophoresis.
Treatment:
Folic acid
Frequent transfusion
Pneumococcal vaccination
Q-226. All of the following are seen in cardiac tamponade except
a) Pulsus paradoxus
b) Diastolic collapse of right ventricle on echocardiogram
c) Electrical Alternans
d) Kussmaul’s sign
Answer: Kussmaul’s sign
Explanation:
Acute cardiac tamponade:
Elevated intra-pericardial pressure > 15 mm Hg
Signs and symptoms:
Pain in inflammatory cases or painless in neoplastic or uremic effusion
Dyspnea and cough
A pericardial friction rub
Tachycardia and tachypnea
Pulsus paradoxus (Also found in obstructive lung disease and asthma) and a relatively preserved systolic pressure
Elevated central venous pressure
Investigation:
Echocardiography is primary method for demonstrating pericardial effusion.
ECG: Non-specific T wave changes and low QRS voltage X-ray chest: Enlarged cardiac silhouette with globular configuration
Treatment:
Urgent paracentesis when tamponade present
Kussmaul’s sign is the paradoxical rise in jugular venous pressure with inspiration.
Causes of Kussmaul’s sign include right ventricular infarction, severe right ventricular failure, restrictive cardiomyopathy, constrictive pericarditis, and tricuspid stenosis.
Q-227. In hematuria of glomerular origin the urine is characterized be the presence of all of the following except
a) Red cell casts
b) Acanthocytes
c) Crenated red cells
d) Dysmorphic red cells
Answer: Acanthocytes
Explanation:
Hematuria of glomerular origin:
Red cell casts
Crenated red cells
Dysmorphic red cells
Important points:
Acanthocytes or spur cells are spiculated red cells with a few projections of varying size and surface distribution.
Acanthocytosis is a red cell phenotype associated with various underlying conditions. The most frequent and most significant conditions include abetalipoproteinemia and spur cell hemolytic anemia of severe liver disease.
Q-228. Polycystic disease of the kidney may have cysts in all of the following organs except
a) Lung
b) Liver
c) Pancreas
d) Spleen
Answer: Lung
Explanation:
Polycystic disease of the kidney has concurrent:
Hepatic cyst
Pancreatic cyst
Splenic cyst
Ovarian cyst
Q-229. A 40 year old man presented with painless hematuria. Bimanual examination revealed a ballotable mass over the right flank. Subsequently right Nephrectomy was done and mass was seen to be composed of cells with clear cytoplasm. Areas of hemorrhage and necrosis were frequent. Cytogenic analysis of this mass is likely to reveal an abnormality of
a) Chromosome 1
b) Chromosome 3
c) Chromosome 11
d) Chromosome 17
Answer: Chromosome 3
Explanation:
Renal Cell carcinoma
Q-230. Which of the following is the drug of first choice for Non-gonococcal urethritis?
a) Ceftriaxone
b) Ciprofloxacin
c) Doxycycline
d) Minocycline
Answer: Doxycycline
Explanation:
Chlamydia trachomatis is the most common cause of non gonococcal urethritis.
Treatment regimen:
Azithromycin or
Doxycycline or
Levofloxacin