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Ans. is 'a' i.e., VDRL for mother and Baby Bullous lesion and periostitis suggest the diagnosis of congenital syphilis. o The only option related to syphilis is option 'a'. o Following evaluations are recommended : - 1. Physical examiation 2. A quantitative nontreponemal test for syphilis (VDRL). 3. CSF for cell count, protein & VDRL. 4. Long bone radiograph 5. Antitreponemal IgM.
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Ans. is 'a' i.e., True negative result
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The diagnosis in the question points towards the diagnosis of Baholin's cyst. Though both surgical resection and marsupialisation are used in the surgical management, the latter is preferred more due to its advantages. Incision and drainage would be appropriate for Baholin's abscess. Aspiration would lead to recurrence and thus not used in the surgical management of Baholin's cyst. The advantages of marsupialisation over surgical resection: The procedure is simple and can be done as a out patient procedure Even local anesthesia would be sufficient Requires only a sho hospital stay as within 24 hours Postoperative complications is very much less as there are increased chances of bleeding with surgical resection Better cosmetic outcome The gland secretion is maintained intact Ref: Dutta Gynaecology 2nd edition page 148, 4th edition, Page 152; Shaw's Textbook of Gynaecology; 13th edition, Pages 196-97; Atlas of Gynecologic Surgery by By Hans A. Hirsch, Otto Kaser, Franz Anton Ikle; 3rd edition, Page 129; Family Practice Guidelines By Jill C. Cash, Cheryl A. Glass; 2nd edition, Pages 322-33
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Ans is "b" i.e. Nasopharyngeal carcinoma Note: Glottic carcinoma never metastasizes to lymph nodes and carcinoma lip metastasizes rarely and very late
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Ans. is 'a' i.e. Verapamil belongs to second group drugs Verapamil is a calcium channel blocker. It belongs to class IV anti-arrhythmic drugs. Electrophysiological properties of verapamil. Among the Ca2+ channel blockers, verapamil has the most prominent cardiac electrophysiological action. It is a cardio depressant drug. Specific effects of verapamil. 1. S.A. nodal atomicity - decrease 2. Ventricular atomicity - decrease 3. A-V nodal ERP - increase 4. PR interval - increase Verapamil A. Uses as Antiarrhythmic PSVT - Preferred for PSVT. The drug of choice for PSVT is Adenosine* Control ventricular rate in AF or AFI. B. Contraindications 1) Partial heart block* 2) Sick sinus* 3) Ventricular arrhythmia (ppt-VF)* 4) Digitalis toxicity (Additive A-V block)*
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Whole-body iodine scan is recommended for differentiated thyroid cancer , which fulfill following conditions : Tumors - between 1cm-4cm Confined to the thyroid Do not have nodal or distant metastasis, Adverse histologic subtype (tall cell) Vascular invasion. =Unlike differentiated thyroid cancer, Medullary thyroid carcinoma cells do not concentrate radioactive iodine and are not sensitive to manipulation of thyroid-stimulating hormone.
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Certain tumors are known to be common sources of bone metastasis. The following primary tumors are the most common to metastasize in the bone; breast, prostate, lung, thyroid, kidney, and gastrointestinal tract.
The commonest source of metastatic bone disease is carcinoma of the breast. In males most common source is prostate carcinoma.
Bladder and uterine carcinomas are less common sources.
In children, skeletal metastases originate from neuroblastoma, Ewing's sarcoma, and osteosarcoma.
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Free fatty acids bound to albumin are increased as a result of an increased activity of Hormone sensitive lipase in adipose tissue as this enzyme breaks TG into glycerol & fatty acids. These fatty acids are taken up by liver. b-oxidation of these fatty acids in liver provides the acetyl CoA for ketogenesis. Hepatic ketogenesis is also stimulated by elevated levels of glucagon during fasting.
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HAA is given in AIDS patients, and has proved to be very effective in decreasing the viraemia and improving the CD count. Incidence of CMV retinitis is markedly decreased in such patients. But due to the improvement in the immunity, the patient stas developing uveitis.
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Zika virus disease is caused by a virus transmitted primarily by Aedes mosquitoes, which bite during the day. Symptoms are generally mild and include fever, rash, conjunctivitis, muscle and joint pain, malaise or headache. Symptoms typically last for 2-7 days. Most people with Zika virus infection do not develop symptoms. Zika virus infection during pregnancy can cause infants to be born with microcephaly and other congenital malformations, known as congenital Zika syndrome. Infection with Zika virus is also associated with other complications of pregnancy including preterm bih and miscarriage. An increased risk of neurologic complications is associated with Zika virus infection in adults and children, including Guillain-Barre syndrome, neuropathy and myelitis. Ref:Park's Textbook of Preventive and Social Medicine 25th Ed Pg.301
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The primary bacterial indicators of contamination of water are the coliform group. Supplementary indicators include faecal streptococci and sulphite-reducing clostridia(C.perfringens) Park's Textbook of Preventive and Social Medicine, 25th edition, Page No. 780,781
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Mucoid colonies are due to the production of the capsule of hyaluronic acid not due to M-protein. Growth characteristic of Strep. pyogenes: On blood agar, virulent stains form matt or mucoid colonies while avirulent from glossy colonies. M, T, R are proteins found on the outer pa of the cell wall and forms the basis of Griffith classification. M protein - acts as virulence factor and antibody against it is protective. T and R protein - No relation to virulence Ref : 208
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Ans. is 'c' i.e., Infected person harbouring infectious agent without clinical features and acts as source of infection Sources and reservoirs* Source is 'the person, animal, object or substance from which infectious agent passes to host\ i.e. man acquires infection from source.* Reservoir is 'any person, animal, insect, plant, soil or substance in which an infectious agent lives and multiplies'. Infectious agent is dependent on reservoir for survival. From reservoir it can be transmitted to susceptible host. Thus a reservoir may act as a source of infection when a person acquires infection directly from a reservoir.# Source & reservoir are same - Tetanus spores survive in soil (reservoir) and a person acquires infection directly from soil (source). So, soil acts as reservoir as well as source.# Source & reservoir different ->>In typhoid, bacillus survives and multiplies inside human cases or carriers (act as reservoir), but immediate source of infection is feces or urine of patients, or contaminated food, water or milk (act as source).# So, source may or may not be a part of reservoir. In other words reservoir may or may not act as a source.* Reservoir may be: (i) Human, (ii) Animals or bird, or (iii) Non-living things.Human reservoir# Human reservoir is the most important source or reservoir of infection. They can be divided into -1. Cases* A case is a person which is having a particular disease. Cases may be of following types -i) Clinical case# Infected case who develops clinical manifestations.ii) Subclinical case (inapparent/covert/missed/abortive case)# Infected person is asymptomatic. Baring a few e.g. measles and chicken pox, sub-clinicalinfection occurs in most cases.# Important examples are rubella, mumps, polio, hepatitis A & B, influenza, diphtheria and Japanese encephalitis.iii) Latent infection# Infectious agent lie dormant in host without any activity, e.g. Herpes simplex, Brill-zinser diseaes, ankylostomiasis.2. Carriers* A carrier is defined as "an infected person or animal that harbours a specific infectious agent in the absence of clinical disease and serves as a potential source of infection".* As a rule carriers are less infectious than cases, but epidemiologically they are more dangerous than cases because they escape recognition, and continuing as they do to live a normal life among the population or comunity, they readily infect the susceptible individuals over a wider area and longer period of time.* Carrier may be classified as followTemporary carrier* Temporary carriers shed the infectious agent for short period of time.* This category may include -1. Incubatory carriers :Measles, mumps, polio, pertussis (whooping cough), influenza, diphtheria, Hepatitis B.2. Convalescent carriers:Typhoid, cholera, diphtheria, Pertussis (whooping cough), dysentery.3. Healthy carriers:Polio, Cholera, meningococcal meningitis, Salmonellosis, diphtheriaChronic carrier* Chornic carriers excrete the infectious agent for indefinite period.* Examples : Typhoid, hepatitis B, dysentery, malaria, gonorrhoea, cerebrospinal menigitis, Diphtheria.Note: Typhoid, hepatitis B and dysentery may have both temporary as well as chronic carriers.* A carrier who acquires infectious agent from other carrier is called 'paradoxical carrier'* A carrier who acquires infectious agent due to contact with patient is called 'contact carrier'.
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Ans. is 'b' i.e., ABER Annual blood examination rate (ABER) is an index of operational efficiency.
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Ans. b. Dehiscent superior semicircular canal Dehiscence of bone overlying the superior semicircular canal can cause a constellation of vestibular and auditory symptoms and signs. These abnormalities can be understood in terms of the effect of the dehiscence in creating a third mobile window into the inner ear.
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Ans. is 'b' i.e., 7 years
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(A) Myopia > In myopia, the axial length of the eyeball is increased while in hypermetropia, the axial length of the eyeball is decreased.
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It is necessary to employ suckling mice for the isolation of coxsackie virus. REF:ANANTHANARAYAN AND PANIKER'S TEXTBOOK OF MICROBIOLOGY 9TH EDITION PAGE NO:491
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Ans. is 'd' i.e.. Inferior epigastric artery Contents of inguinal canalo Spermatic cord in male or round ligament of uterus in female.o Ilioinguinal nerve : It enters through the interval between external and internal oblique muscles,\o Genital branch of genitofemoral nerve is a constituent of spermatic cord.
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(Isoflurane) (134-Lee's 13th) (373 - KDT 6th)ISOFLURANE - Repeated iso flurane administration have failed to produce measurable changes in liver function Renal and hepatic toxicity has not been encountered.* Anaesthetic choice in - Neurosurgery and safer in myocardial ischaemiaSEVOFLURANE - anaesthetic choice in Liver / Kidney diseases* It may trigger malignant hyperpyrexia in susceptible individuals* Well tolerated in both children and adults* Muscle relaxant of choice in hepatic & renal failure - cisatracurium**
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Sarilumab: Monoclonal antibody against IL6, used for rheumatoid ahritis. Six - SARILUMAB - monoclonal antibody | Interleukin Durvalumab: Monoclonal antibody for urothelial carcinoma. DURVALUMAB - Urothelial Ca Nivolumab/Sarilumab: Monoclonal antibody for non small cell lung cancer(NSCLC). Durvalumab, Nivolumab, Sarilumab: Target program death ligand of T cell. T cell get activated and kills cancer cells.
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Cryoprecipitate has a higher concentration of Factor VII (80 IU in 15 ml of plasma) compared to FFP (200 IU in 200 ml). Thus, cyroprecipitate has a higher concentration on Factor VIII.
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An elevated alkaline phosphatase level in an older adult should raise the suspicion of bone metastases, particularly when there is a "pathologic" fracture resulting from a bone lesion, rather than a fracture from trauma. Likely primary sites include the breast (in women), prostate (in men), lung (in smokers), kidney, and thyroid. Hyperparathyroidism can lead to osteitis fibrosa cystica with lytic lesions that are usually small, involve just the cortex, and appear first in phalanges. Multiple myeloma can produce lytic bone lesions, but the patient's serum gamma globulin level is not elevated. Osteochondromas are exostoses and do not produce lytic bone lesions. Paget disease of bone is characterized by osteolysis coupled with bone formation but without lytic lesions. Fibrous dysplasia coupled with cafe-au-lait spots on the skin and with endocrinopathies is known as McCune-Albright syndrome; this is a rare condition that occurs in young girls.
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Serotonin is a vasoconstricting hormone, produced in the brain and GI tract. In the GI tract it is produced normally by enterochromaffin cells (argentaffin cells). The principal function is to regulate smooth muscle contraction and peristalsis. Serotonin: also called 5-hydroxytryptamine, is a chemical substance that is derived from the amino acid tryptophan. Principally found stored in three main cell types; (a) Serotonergic neurons in the CNS and in the intestinal myenteric plexus, (b) Enterochromaffin cells in the mucosa of the gastrointestinal tract and (c) Blood platelets Synthesis: Serotonergic neurons and enterochromaffin cells can synthesize serotonin from its precursor amino acid L-tryptophan, whereas platelets rely upon uptake of serotonin for their stores. The biochemical pathway for serotonin synthesis initially involves the conversion of L-tryptophan to 5-hydroxytryptophan by the enzyme L-tryptophan hydroxylase. This enzyme provides the rate limiting step for serotonin synthesis. Metabolism of serotonin is carried out primarily by the enzyme monoamine oxidase (MAO), The action of MAO conves serotonin to 5-hydroxyindole acetaldehyde which in turn is readily metabolized by aldehyde dehydrogenase to produce 5-hydroxyindole acetic acid as the major excreted metabolite of serotonin. Carcinoid syndrome: are neuroendocrine tumours (NETs) of predominantly enterochromaffin cell origin (Kulchitsky cells).Carcinoid syndrome is made up of a constellation of symptoms which are caused by the release of a variety of substances (serotonin, histamine, and substance P, among others) by the carcinoid tumor. It may cause trytophan deficiency and causes decrease in niacin synthesis leading to pellagra. Ref: Principles of medical physiology, By Sabyasachi Sicar, Page 641.
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These drugs act by Nucleoside reverse transcriptase inhibition
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Intermediate host-man Definitive host-mosquito Asexual development-man Sexual development-mosquito Sporozoite infective form.Sporozoites are present in the salivary gland of the mosquito .Man gets infection by the bite of female anopheles mosquito (refer pgno:55 baveja 3 rd edition)
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Rubella infection is acquired by inhalation or transplacental route. Ref: Baveja textbook of microbiology; 4th edition
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To differentiate color coding is given to the cylinders . Blue - N20 Black - N2 Orange - Cyclopropane Grey - Co2 Black body with white shoulder - O2 Black body with brown shoulder - Heliox ( Helium + 02 )
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Testicular feminization syndrome (androgen insensitivity syndrome): XY karyotype with a female phenotype androgens are present but do not act at a peripheral level due to a receptor defect. the embryological development, which is dependent on androgens in a male fetus, does not happen and hence by default a female form is made. breast development is seen due to peripheral conversion of androgens to estrogens The inguinal swellings described in the question are actually the testes
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Post pattum hemorrhage is the main cause of maternal deaths. It account for about 25%.REF. PARK'S TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICAL 21ST EDITION. PAGE NO - 516
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Abductor pollicis brevis and flexor pollicis brevis, both are supplied by the median nerve. However, flexor pollicis brevis cannot be tested separately because flexion of metacarpophalangeal joint of the thumb (the function of flexor pollicis brevis) can also be produced by flexor pollicis longus. On the other hand abductor pollicis brevis can be tested separately.
Option 'c & d' are incorrect in regards to this question. Though, sensory loss over palm (lateral 2/3) and ring finger (lateral half) occurs in median nerve injtuy, these area are not used to test sensory loss. For testing, the sensory deficit in median nerve injury tip of the index and middle finger (autonomous zone) are used.
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Ans. a. Amoebic dysentery
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Ans. (a) Diabetes mellitus (b) Total parenteral nutrition (c) Tuberculosis * In acalculous cholecystitis, there is acute inflammation of gallbladder without gallstones.* In over 50% of cases of acalculous cholecystitis an underlying explanation is not found.* Acalculous cholecystitis typically develop in critically ill patients in the ICU. Patients on parenteral hyperalimentation with extensive burns, sepsis, major operations, multiple trauma or prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis.* Harrison writes* "An increased risk for the development of acalculous cholecystitis is especially associated with serious trauma or burns, with the postpaum period following prolonged labor, and with ohopedic and other nonbiliary major surgical operations in the post operative period. It may possibly complicate periods of prolonged parenteral hyperalimentation. For some of these cases, biliary sludge in the cystic duct may be responsible. Other precipitating factors include- vasculitis- obstructing adenocarcinoma of the gall bladder- diabetes mellitus- torsion of the gall bladder- unusual bacterial infections of the gall bladder (eg. Leptospira, Streptococcus, Salmonella, or Vibrio cholera), andparasitic infestation of gallbladder.* Acalculous cholecystitis may also be seen with a variety of other systemic disease processes- sarcoidosis - syphilis- cardiovascular disease - actinomycosis- tuberculosis* Clinical manifestation- is indistinguishable from those of calculuos cholecystitis, however, the setting of cholecystitis in severe underlying illness is characteristic of acalculous cholecystitis.* U/S & CT examinations show a large, tense, static gallbladder without stones and with evidence of poor emptying over a prolonged period. Ultrasonography is usually the diagnostic test of choice, as it can be done bedside in the intensive care unit.* ManagementThe complication rate of acalculous cholecystitis is more than calculous cholecystitis.- Acalculous cholecystitis requires urgent intervention.- Percutaneous ultrasound or CT guided cholecystostomy is the treatment of choice for these patients, as they are unfit for surgery.- If the diagnosis is unceain, percutaneous cholecystostomy is both diagnostic and therapeutic. About 90% of patients will improve with the percutaneous cholecystostomy. However, if they do not improve, other steps, such as open cholecystostomy or cholecystectomy, may be required.If needed cholecystectomy can be done after the patient has recovered from the underlying disease.
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Ans. is 'b' i.e., Fecal-oral route . Polio transmission is mostly restricted to developing countries where fecal-oral route is the most common mode of transmission.
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Streptococcal pyrogenic toxin (SPE) is also called erythrogenic or Dick or scarlatinal toxin. This toxin was named 'erythrogenic' because its intradermal injection into susceptible individuals produced an erythematous reaction. SPEs are superantigens which are T cell mitogens that induce a massive release of inflammatory cytokines, causing tissue damage, fever and shock. Soft tissue infections with some M types of S.pyogenes may sometimes cause a toxic shock syndrome resembling staphylococcus TSS. Streptococcal TSS and necrotizing fasiculitis occur in persons not immune to the infecting M types. Ref: Textbook of Ananthanarayan and paniker's; 10th Edition; Pg:213, 215.
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Foley's catheter
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A solitary hypoechoic lesion without any septae or debris is most likely to be a simple cyst. However rarely a hydatid cyst can have a similar sonologic appearance. Simple cysts are the most common benign lesions found in liver. On imaging studies they appear as unilocular, homogenous fluid-filled structures with a thin wall without projections, septa or debris. Ultrasound appearances of - Hydatid cyst - It presents either as a simple cyst with hydatid sand or daughter cysts or floating endocyst or calcification. Caroli's disease - Its the type V choledochal cyst Multiple intrahepatic biliary cysts are seen on ultrasound. Sludge & stones may also be visible within the cysts. Liver abscess - Sonographic appearance may include a cystic lesion with floating internal echoes and irregular margins. Septations, debris and fluid-fluid interfaces may also be seen. Ref : Rumack's Diagnostic Ultrasound 3rd/e, p. 86, 89, 94, 1865
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Ans. is 'b' i.e., Agglutination of ricketssial suspension * Both epidemic typhus and endemic typhus are positive for OX-19 antigen - Thus Weil Fleix reaction cannot differentiate between the two.Serological diagnosis of Rickettsial infection* Serological diagnosis may be made by :-i) Heterophile Weil-Felix reaction.ii) Specific tests using rickettsial antigens.A) Weil-Felix reaction* This reaction is an agglutination test in which sera are tested for agglutinins to O antigens of certain nonmotile proteus strains OX -19, OX - 2 and OX - K.* The basis of the test is the sharing of an alkali - stable carbohydrate antigen by some rickettsiae and by certain strains of proteus, P. vulgaris OX - 19 and OX - 2 and P. mirabilis OX - K.* The test is usually done as a tube agglutination, though rapid slide agglutination methods have been employed for screening.1) Scrub typhus is positive with OXK.2) Epidemic typhus and endemic typhus are positive for OX-19.3) Rocky mountain spoted fever is positive with OX-19 and OX-2.4) Q fever, trench fever and rickettsial pox do not show positive test with any of the three antigen. Thus Weil Felix test is not useful in these disease.DiseaseOX-19OX-2OX-KRocky Mountain spotted fever++-Rickettsial pox---Epidemic typhus+--Bril - Zinsser disease+/---Scrub typhus--+Endemic typhus+--Trench fever---Q fever---B) Specific tests using rickettsial antigens* Following antigens are used:-i) Group specific soluble antigen - More commonly used.ii) Type specific washed rickettsial antigen - Necessary for differentiation between epidemic and endemic typhus.* Tests used to detect these antigens are :-i) Complement fixation test (most commonly used).ii) Agglutination of rickettsial suspensions.iii) Passive agglutination of red cells sensitized by ESS (erythrocyte sensitising substance)iv) Toxin neutralisationv) Immunofluorescensevi) Radioisotope precipitation
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Ans. is 'b' i.e., Tumours derived from Rathke's Pouch Craniopharyngiomao Craniopharyngioma is a type of brain tumor derived from pituitary gland embryonic tissue that occurs most commonly in children but also in men and women in their 50s and 60s. People may present with bitemporal inferior quadrantanopia leading to bitemporal hemianopsia, as the tumor may compress the optic chiasm.o Craniopharyngiomas are also known as Rathke pouch tumors, hypophyseal duct tumors, or adamantinomas.
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In addition to the three basic principles of radiation protection (justification, limitation, and optimization), one can apply the following additional techniques to reduce the radiation burden to the patient:
Collimation of the x-ray beam.
Correct focus-to-skin distance.
Lead apron with thyroid collar.
More radiation-sensitive image receptors.
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Craniofacial abnormalities are common in O.S.A in non-obese patients and children. Non structural risk factors for OSA include: Obesity, central fat distribution Male sex, middle age Alcohol use, sedative use, smoking Supine sleep position
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Ans. B. Eleks gel precipitation testNeil Mooser reaction is done in guinea pigs for Rickettsia rickettsiae (Scrotal necrosis) and tunica reaction (Rickettsia conorii, Rickettsia akari and Rickettsia typhi)
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Restless leg syndrome / Ekbom syndrome. Sensorimotor disorder, commonly seen in 5-15% of the population. Affects females and after 40 years. 4 salient diagnostic features being: Urge to move limbs, commonly associated with premonitory sensory discomfo Motor restlessness Relief by activity Evening/Night worsening Pathophysiological explanations or mechanisms attributed are: Dysregulation of dopamine transmission Intracellular iron dysregulation. This can be objectively substantiated by decreased CSF ferritin and prohepcidin (Intracellular regulatory protein for iron) levels.
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Cholecystovenacaval line: - Is an imaginary line which passes through groove for IVC to the gallbladder fossa and separates right & left hepatic lobe functionally.
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A small medial area of the superior pole is related to the left suprarenal gland. Approximately the upper two-thirds of the lateral half of the anterior surface is related to the spleen. A central quadrilateral area lies in contact with the pancreas and the splenic vessels. Above this a small variable triangular region, between the suprarenal and splenic areas, is in contact with the stomach. Below the pancreatic and splenic areas, a narrow lateral strip which extends to the lateral border of the kidney is related to the left colic flexure and the beginning of the descending colon. Ref: Gray's anatomy 40th edition, Chapter 91.
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sho-acting beta2 agonists- salbutamol., terbutaline, pirbuterol long-acting- salmeterol, formoterol, clenbuterol ref kd Tripathi 8th ed
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Hanup disease - autosomal recessive disease due to mutation in SLC6A19 which cause: Inability to absorb neutral amino acid from intestine and renal cell Tryptophan absorption is severely affected. C/f Pellagra like symptoms- As tryptophan is required for Niacin synthesis. amino aciduria Increased urinary output of indoleacetic acid and indolepyruvic acid is also observed
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Behavioral therapy like using alarms is the treatment of choice for Nocturnal enuresis.
Desmopressin is the drug of choice for Nocturnal enuresis although Imipramine and Oxybutynin are also used.
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Answer- C. Erosion of epithelium + underlying inflammationCorneal ulcer refers to discontinuation in normal epithelial surface of cornea associated with necrosis of the surrounding corneal tissue
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Ans. is 'c' i.e., Corynebacterium diphtheriae
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Long Bone Diaphysis (shaft) - derived from primary ossification center. * present at 6 - 8 weeks of IUL. Epiphysis (ends) - derived from secondary ossification center. * appear after bih Except - Lower end of femur & sometimes upper end of tibia. | Their secondary ossification center appears before bih.
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(B) tricuspid incompetence # Tricuspid regurgitation causes the v wave to be more prominent; when tricuspid regurgitation becomes severe, the combination of a prominent v wave and obliteration of the x descent results in a single large positive systolic wave.> After the v wave peaks, the right atrial pressure falls because of the decreased bulging of the tricuspid valve into the right atrium as right ventricular pressure declines and tricuspid valve opens# Jugular venous pulse> Normal: 3 +ve pulse waves -a, c and v 2 -ve pulse waves -x and y> 'a'wave: Due to right atrial contraction Synchronous with carotid artery pulse> Absent'a'wave : Atrial fibrillation> Diminished 'a' wave: Tachycardia Prolonged PR interval> 'a' Wave Fused with (c' Wave: Supra ventricular tachycardia> Large 'a' Waves : Pulmonary hypertension Pulmonary stenosis Tricuspid stenosis Tricuspid atresia AV dissociation> Cannon Waves (Giant 'a' Waves) : Complete heart block when right atrium occasionally contracts against closed tricuspid valve Ventricular tachycardia Ectopic beats> Regular 'a' Waves : AV junctional rhythm 10AV block 2 : 1 AV block Atrial tachycardia> Irregular 'a' Waves: Premature systoles: Atrial Ventricular AV junctional Complete AV dissociation: Complete AV block AV junctional tachycardia Ventricular tachycardia Atrial flutter> Non-conducted 'a' waves: Atrial tachycardia Atrial flutter with block> 'c' Wave : Produced by Impact of carotid artery to jugular vein Retrograde transmission of positive wave in right atrium (by ventricular systole and bulging of tricuspid valve into right atrium). Carotid artefact Systolic bulging of tricuspid valve into RA> V Wave: Absent 'x' wave: Constrictive pericarditis Restrictive cardiomyopathy ASD (sometimes)> v Wave : during ventricle contraction caused by atrial filling and occurs with and just after carotid pulse.# Large V Waves: Tricuspid regurgitation ASD Anomalous pulmonary venous drainage, Right sided heart failure> 'y' Wave: Slow Descent y Wave : Tricuspid stenosis Sharp Descent y Wave : Constrictive pericarditis Rapid Descent y wave : Constrictive pericarditis (Friedreich's sign) Severe heart failure Tricuspid regurgitation
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Answer is A (Protein| sugar|): CSF proteins are increased and glucose levels are characteristically decreased.
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The infectious agents listed are all impoant causes of congenital disease. The triad of cutaneous hemorrhages ("blueberry muffin baby"), deafness, and periventricular CNS calcifications suggests congenital CMV infection, the most common cause of intrauterine fetal viral infection. Other manifestations include microcephaly and hepatosplenomegaly. Neonatal herpes may be congenital, but more commonly is acquired during vaginal delivery. The infection is characterized by vesicles on the skin and mucous membranes, encephalitis, or disseminated disease. Congenital rubella can cause mental retardation, hea abnormalities, blindness, encephalitis, and motor abnormalities. Congenital syphilis can cause death in utero, or a variety of problems including abnormal teeth, bones, and central nervous system.
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Ans. A. Combination should be avoidedRef: Harrison's Principles of Internal Medicine 19th/ed, p2147Explanation# Option a: Anakinra (IL 1 antagonist) and infliximab (anti-TNF) should not be combined.# Both agents restrict inflammatory process markedly and lead to high rate of serious infections.# This finding is observed in trials that used this regimen.# New strategy in treatment of RA focuses on several goals:1. Early, aggressive therapy to prevent joint damage and disability.2. Frequent modification of therapy and use of combination therapy where appropriate.3. Individualization of therapy, to maximize response and minimize side effects;4. Achieving, remission of clinical disease activity.# Preferred first line drug as monotherapy in moderate to severe RA: Methotrexate# Effective combinations include:# Methotrexate, sulfasalazine, and hydroxychloroquine (oral triple therapy);# Methotrexate and leflunomide;# Methotrexate plus a biological (e.g. methotrexate and infliximab an anti-TNF agent; methotrexate + Etanercept is equivalent to oral triple therapy options b and d)# Early RA (<6 months of disease duration)# Started with methotrexate - switch or add DMARD therapy after 3 months of worsening or persistent moderate/high disease activity - If disease still persists after 3 months of intense DMARD therapy, add a biologic agent.# Oral triple therapy (hydroxychloroquine, methotrexate, and sulfasalazine) is a reasonable first step for the treatment of early RA, including its use as a step-up strategy where treatment is initiated with methotrexate alone and then combined at 6 months with hydroxychloroquine and sulfasalazine if the disease is not adequately controlled.# Patients with established RA.# Treatment with a biologic agent or aggressive combination DMARD therapy was also recommended as initial therapy in certain patients with high disease activity and poor prognosis.
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Village health guides
A village health guide is a person with an aptitude for social service and is not a full time government functionary.
The health guides are now mostly women.
The health guides come from and are chosen by the community.
They serve as links between the community and the government infrastructure and provide the first contact between the individual and the health system.
Selection
The guidelines for their selection are : -
They should be permanent residents of the local community.
They should be able to read & write (minimum education upto VI standard).
They should be able to spare at least 2 to 3 hours every day for community health work.
They should be acceptable to all sections of the community.
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Ans is a i.e. anencephaly
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Complicatiosn of Talar neck fracture
Malunion
Avascular necrosis (osteonecrosis) of body.
Non-union
Secondary osteoarthritis of ankle and subtalar joint.
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Primary causes of microcephaly in children are - Mnemonic - Cannot See PEFR in Children Cri-du-chat Syndrome Smith Lemli Optiz Syndrome Patau syndrome Edward syndrome Familial Rubinstein Taybi syndrome Cornelia de Lange syndrome Also Know Acquired MIcrocephaly Q R - Rett's syndrome A - Angelmann Syndrome S - Seckel syndrome Also know some impoant causes of macrocephaly * Taysach's * MPS * Ganghosidosis * Sotos - Fragile x syndrome - Alexander disease - Canavan disease - Neuro cutaneous syndromes
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Aoic Stenosis REF: Harrison's 17th ed chapter 220 Anacrotic pulse with a slow initial upstroke, the peak is close to S2; these features suggest fixed left ventricular outflow obstruction, such as occurs with valvular aoic stenosis
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> 8 days
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i.e. (Mitochondria) : (301-Harsh Mohan 6th ) (625-Robbins & Cotran-Pathologic basis of disease 8th)Ringed sideroblasts is characteristic of sideroblastic anemia /Myelodysplastic SyndromeRinged sideroblast in which haem synthesis is disturbed as occurs in sideroblastic anaemiasRinged sideroblasts containing numerous large granules, often forming a complete or partial ring around the nucleus. These ringed arrangement of these granules is due to presence of iron laden mitochondria around the nucleus
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The criteria to diagnose a right bundle branch block on the electrocardiogram: The hea rhythm must originate above the ventricles (i.e., sinoatrial node, atria or atrioventricular node) to activate the conduction system at the correct point. The QRS duration must be more than 100 ms (incomplete block) or more than 120 ms (complete block). There should be a terminal R wave in lead V1 (often called "R prime," and denoted by R, rR', rsR', rSR', or qR). There must be a prolonged S wave in leads I and V6 (sometimes referred to as a "slurred" S wave). The T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest ischemia or myocardial infarction. Ref Harrison 20th edition pg 1432
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Palivizumab is a monoclonal antibody used for the prevention of Respiratory syncytial virus
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.cyclodevelopmental form of life cycle is the one in which the disease agent undergoes only development but no multiplication.examples include mainly the life of microfilaria in mosquito. ref:park&;s textbook of preventive and social medicine,edition 22,pg no 94
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Clinical Features of datura * Dryness of mouth (dry as bone) * Bitter taste * Difficulty in talking * Dysphagia--- these are first noted * Dilated pupils * Diplopia * Difficulty in vision (blurring of vision, blind as bat) * Dry hot skin with flushing (red as beet) * Hyperpyrexia (hot as hare) * Drunken gait (ataxia) * Hyperreflexia * Convulsions * Delirium, hallucinations, agitation, amnesia, incoherence, visual or auditory hallucinations (mad as a hen) * Deficit of recent memory. Remote memory undisturbed * Dysuria * Distention of bladder (retention of urine) * Death. REF;THE SYNOPSIS OF FORENSIC MEDICINE:KS NARAYANA REDDY;28th EDITION;PAGE NO 344
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Poxviruses causing disease in humans
Variola (small pox)
Buffalopox
Cowpox
Vaccinia
Monkeypox
Molluscum contagiosum
Tanapox
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Bile and the fluids found in the duodenum, jejunum, and ileum all have an electrolyte content similar to that of Ringer lactate. Saliva, gastric juice, and right colon fluids have high K+ and low Na + content. Pancreatic secretions are high in bicarbonate. It is impoant to consider these variations in electrolyte patterns when calculating replacement requirements following gastrointestinal losses.
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Isoxazole derivative of 17 - alpha ethinyl testosterone propeies Causes atrophy of endometrium It is strictly antigonadotropin but acts as an androgen agonist Mode of action Acting on the hypothalamo - pituitary - gonadal axis - depression of frequency of GnRh pulses - suppression of pituitary FSH and LH surge. There is however no change in the basal gonadotropin level Indication of danazol Endometriosis DUB Symptomatic fibroid Precocious pubey
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Ans. is 'a' i.e., Inflammation of anal gland
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Tofacitinib : Janus kinases are intracellular enzymes that modulate immune cell activity in response to the binding of inflammatory mediators to the cellular membrane. Tofacitinib is an oral inhibitor of Janus kinases indicated for the treatment of moderate to severe RA in patients who have had an inadequate response. Biological DMARDS: TNF - alpha IL -1R blocker IL-6 blocker Co stimulation inhibitor A: Adalimumab C: Ceolizumab E: Etercenept I: Infliximab Goli: Golimumab ANAKINRA TOCLIZUMAB SARILUMAB ABATACEPT
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Splenomegaly, variceal bleeding in the absence of hepatomegaly suggest the diagnosis of non-cirrhotic portal fibrosis.
Non-Cirrhotic Portal Fibrosis
Its incidence is very high in India accounts for 15% to 18% of all patients with portal hypertension. Aetiology :
Infection → It was suggested that E.coli can cause NCPF
Exposure to chemicals → Chronic ingestion of Arsenic is incriminated in causing NCPE Vinyl Chloride toxicity can also cause NCPF
Clinical features :
Symptoms :
Patients are usually young in 3rd or 4th decade of life.
Gastrointestinal haemorrhage is the most common presenting symptom seen in 60-90% of patients.
Lump in the left side of Abdomen d/t enlargement of the spleen
Jaundice & Ascites uncommon and if they do occur it is for a short period of time. Signs
Splenomegaly (usually massive)
The liver usually normal in size
Sometimes mild ascites can be seen.
Endoscopy :
Esophageal varices are detected in over 90% of patients
Rectal varices in 70% of patients.
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Mercury Poisoning Acute effect * By ingestion: local corrosive effects; nausea, vomiting, severe abdominal pain, chemical colitis, renal damage * By inhalation: chemical pneumonitis, pulmonary edema Chronic effect * Classic symptoms: tremor, gingivitis, erethism (greek erethismos = irritate) * Renal & CNS damage * Minamata disease - neurological syndrome caused by severe mercury poisoning REF : NARAYANA REDDY TOXICOLOGY
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Answer- A. Gas gangreneCrepitus in soft tissue is characteristic of gas gangrene.Edema, crepitus and brown exudate after injury suggest the diagnosis of gas gangrene.
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(B) 20-50 mg/dL CEREBROSPINAL FLUIDConstituentReference RangeSI UnitsConventional UnitsOsmolarity292-297 mmol/kg water292-297 mOsm/LElectrolytes * Sodium137-145 mmol/L137-145 meq/L* Potassium2.7-3.9 mmol/L2.7-3.9 meq/L* Calcium1.0-1.5 mmol/L2.1-3.0 meq/L* Magnesium1.0-1.2 mmol/L2.0-2.5 meq/L* Chloride116-122 mmol/L116-122 meq/L* CO2 content20-24 mmol/L20-24 meq/LPCO26-7 kPa45-49 mmHgpH7.31-7.34 Glucose2.22-3.89 mmol/L40-70 mg/dLLactate1-2 mmol/L10-20 mg/dLTotal protein: * Lumbar0.15-0.5 g/L15-50 mg/dL* Cisternal0.15-0.25 g/L15-25 mg/dL* Ventricular0.06-0.15 g/L6-15 mg/dL* Albumin0.066-0.442 g/L6.6-44.2 mg/dL* IgG0.009-0.057 g/L0.9-5.7 mg/dLCEREBROSPINAL FLUID* IgG index0.29-0.59 * Oligoclonal bands (OGB)<2 bands not present in matched serum sample Ammonia15-47 mmol/L25-80 ng/dLCreatinine44-168 pmol/L0.5-1.9 mg/dLMyelin basic protein<4 ng/L CSF pressure 50-180 mmH2OCSF volume (adult)-150 mL Red blood cells00Leukocytes Total0-5 mononuclear cells per pL Differential * Lymphocytes60-70% * Monocytes30-50% * NeutrophilsNone
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Idiopathic juxtafoveolar retinal telangiectasis is characterized by abnormal retinal capillaries with variable intraretinal exudation after exclusion of an ocular or systemic cause. It was also termed as Idiopathic macular telengietasias. Group 1 unilateral juxtafoveal telangiectases represents a localized form of congenital retinal telangiectasis (Coats' syndrome). Juxtafoveal Retinal Telengiectasias have not been mentioned in association with peripheral telengiectasias. Thus Associated with peripheral telegiectasias is the correct answer. Ref: Vitreo-retinal Disease by Regillo (1999)/200; Yanoff Ophthalmology 3rd / 633; Text book of ocular diseases by Kanski 6th/614
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The organisms which produce the pigment chiefly in the dark are called scotochromogens. M. scrofulaceum causes scrofula, a granulomatous cervical adenitis, usually in children. (M. tuberculosis also causes scrofula.) The organism enters through the oropharynx and infects the draining lymph nodes. Its natural habitat is environmental water sources, but it has also been isolated as a saprophyte from the human respiratory tract. Scrofula can often be cured by surgical excision of the affected lymph nodes. Mycobacterium fouitum-chelonae complex is composed of two similar species, M. fouitum and M. chelonei. They are saprophytes, found chiefly in soil and water, and rarely cause human disease. Infections occur chiefly in two populations: (1) immunocompromised patients and (2) individuals with prosthetic hip joints and indwelling catheters. It is a rapidly growing mycobacteria. M. kansasii causes lung disease clinically resembling tuberculosis. It is a photochromogen. Do You Know: Mycobacterium marinum causes "swimming pool granuloma," also known as "fish tank granuloma". Ref - Levinson W. (2012). Chapter 21. Mycobacteria. In W. Levinson (Ed), Review of Medical Microbiology & Immunology, 12e.
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Ans. (c) Whipple's SurgeryRef: Bailey and Love 26th/e p. 1139* Whipple's Pancreaticoduodenectomy is the Surgical Treatment of Choice for Distal CBD cancer, Periampullary cancer and Pancreatic head cancer
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Refer Robbins page no Pg 8th/786 In medicine, the Sister Mary Joseph nodule or more commonly node, also called Sister Mary Joseph sign, refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen
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PoxvirusesGenusVirusPrimary HostDiseaseOhopoxvirus1. VariolaHumansSmallpox 2. VacciniaHumansFor smallpox vaccination3. CowpoxCowsRare in Humans4. MonkeypoxMonkeysRare in HumansMolluscipoxvirusMolluscum contagiosumHumansBenign skin nodulesParapoxvirus1. Orf2. Pseudocowpox3. Bovine papular stomatitisSheepCowsRare in HumansYatapoxvirus1. Tanapox2. YabapoxMonkeysRare in HumansChicken pox belongs to Herpes virus familyReference: Jawetz, Melnick, & Adelberg's Medical Microbiology; 27th edition; Chapter 34; Poxviruses
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Ans. is 'a' i.e., Erythema annulase cetrifugam Erythema annulare centrifugum : an asymptomatic or pruritic eruption of variable duration. The eruption may be associated with an underlying disease (eg, infection, malignancy, sarcoidosis, other systemic illness) The eruption begins as erythematous papules that spread peripherally while clearing centrally. These lesions enlarge at a rate of approximately 2-5 mm/d to produce annular, arcuate, figurate, circinate, or polycyclic plaques Lesions demonstrate a predilection for the thighs and the legs, but they may occur on the upper extremities, the trunk, or the face. The palms and the soles are spared. Erythema migrans: These lesions are typically less numerous, less circinate in configuration, and often accompanied by a history of a tick bite. Erythema gyratum repens: EAC can be distinguished from this condition by its slower rate of spread and by its less bizarre configuration. Also, erythema gyratum repens is almost always associated with an underlying malignancy. Erythema marginatum rheumaticum: This is a nonscaling gyrate erythema that by definition is found in association with rheumatic fever (10-18% of patients with rheumatic fever).
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B i.e. 200 - 300 mg
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Physiological jaundice: the peak serum bilirubin level does not exceed 15mg/dl.
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Amikacin is the second line antitubercular drug.Kanamycin, Amikacin and Capreomycin are more toxic antibiotics used as reserve drugs in rare cases not responding to the usual therapy, or infection by atypical mycobacteria. Any one of these is used at a time in combination with the commonly employed drugs to which resistance has not developed. Because all exhibit similar ototoxicity and nephrotoxicity, they are not combined among themselves or with streptomycin. Capreomycin, in addition, can induce electrolyte abnormalities. All act by inhibiting protein synthesis. None is effective orally; none penetrates meninges. All are excreted unchanged by the kidney. All are given in a dose of 0.75-1 .0 g i.m. per day. ESSENTIALS OF MEDICAL PHARMACOLOGY K.D.TRIPATHI SIXTH EDITION Page NO:744
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Ans. is 'a' i.e., Iliac lymph nodes Lymphatic drainage of uterus & cervix1) Cervix (lower lymphatics) Lymphatics drain into external iliac, internal iliac, and sacral nodes.2) Lower part of body (middle lymphatics) Lymphatics drain into the external iliac nodes.3) Fundus and upper part of body (upper lymphatics) Lymphatics drain mainly into para-aortic nodes and a few lymphatics from the uterine cornu accompany the round ligaments to reach the superficial inguinal nodes.
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Section 304A in The Indian Penal Code Causing death by negligence: Whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both. Ref - Krishnan Vij 5th edition 206
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Ans. is 'b' i.e., Sternocleidomastoid o Accessory nerve (eleventh cranial nerve) has two rootsy cranial and spinal.o Spinal accessory supplies :SternocleidomastoidTrapeziuso Follow ing are the 2 parts of the accessory nerve with their distribution:I Spinal part1 Sternocleidomastoid2. TrapeziusIICranial partMuscles of the pharynx except stvlopharyngeus which is supplied by the glossopharyngeal nerveMuscles of the palate except tensor veli palatini which is supplied by the mandibular division of the trigeminal nerve.o All muscles of the tongue are supplied by the hypoglossal nerve except palatoglossus which is supplied by the accessory nerve.
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Morphine is not an inducing agent.
Sevoflurane is the agent of choice and is used in N2O + O2 gas mixture. Halothane is the second choice inducing agent.
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A i.e. 3rd week
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Ans. B: Impaired bacteriolysis Chediak-Higashi syndrome is a rare autosomal recessive disorder that affects multiple systems of the body, and arises from a mutation in the lysosomal trafficking regulator gene, LYST. It is a disease with impaired bacteriolysis due to failure of phagolysosome formation. As a result of disordered intracellular trafficking there is impaired lysosome degranulation with phagosomes, so phagocytosed bacteria are not destroyed by the lysosome's enzymes. In addition, secretion of lytic secretory granules by cytotoxic T cells is also affected. The disease is characterised by large lysosome vesicles in phagocytes (neutrophils), which thus have poor bactericidal function, leading to susceptibility to infections, abnormalities in nuclear structure of leukocytes, anemia, and hepatomegaly. There are several manifestations of Chediak-Hegashi syndrome. However neutropenia seems to be the most common. The syndrome is also associated with oculocutaneous albinism Persons are also prone for infection, especially with Staphylococcus aureus. Associated features: Abnormalities in melanocytes (albinism), nerve defects, bleeding disorders.
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The rule of res ipsa loquitur means 'the thing or fact speaks for itself'. The rule is applied when the following conditions are satisfied: In the absence of negligence the injury would not have occurred ordinarily The doctor had exclusive control over the injury producing instrument or treatment The patient was not guilty of contributory negligence Ref: Essentials of Forensic Medicine and Toxicology by Narayan Reddy, 27th edition, Page 33.
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Fimbriae
Some gram negative bacilli carry hair like projections called fimbriae or pilli.
Pilli are composed of antigenic pilin.
They are unrelated to motility and are found on motile as well as nonmotile bacteria.
Fimbriae function as organs of adhesion, helping the cells to adhere firmly to particles of various kind.
A special type of fimbriae is sex pills. These are found on 'male' bacteria and help in conjugation by forming conjugation tube through which genetic material is transferred from the donor to the recipient cell.
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Fetal fissure is closed by 6th week Failure to close can lead to formation of coloboma(eg- pear shaped coloboma of iris,chorioretinal coloboma i)
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Soft Tissue Sarcoma- Most common type of STS - Liposarcoma > Leiomyosarcoma- H/F type is site dependent- Extremity (MC site) - MFH (Malignant fibrous histiocytoma)- Retroperitoneum - liposarcoma- Viscera - GIST
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Ans. is 'a' i.e., Fenoldopam Summary And Recommendations for prevention of contrast induced nephropathy (uptodate recommendation )o Optimal therapy to prevent contrast-induced acute renal failure remains uncertain. Patients with near-normal renal function are at little risk and few precautions are necessary other than avoidance of volume depletion.o We recommend the following preventive measures for patients at increased risk of contrast nephropathy, which is defined a serum creatinine >1.5 mg/dL (132 micromol/L) or an estimated glomerular filtration rate <60 ml/l 73 m2, particularly in those with diabetes.o Use, if possible, ultrasonography, MRI without gadolinium contrast, or CT scanning without radiocontrast agents.o We recommend NOT using high osmolal agents is not recommendedo We recommend the use of iodixanol or nonionic low osmolal agems such as iopamidol or ioversol rather than iohexol.o Use lower doses of contrast and avoid repetitive, closely spaced studies.o Avoid volume depletion and nonsteroidal anti-inflammatory drugs.o If there are no contra indications to volume expansion, we recommend isotonic intravenous fluids prior to and continued for several hours after contrast administration. The optimal type offluid and timing of administration are not well established. We suggest isotonic bicarbonate rather than isotonic saline.o Despite conflicting data, we suggest that acetylcysteine be administered the day before and the day of the procedure, based upon its potentialfor benefit and low toxicity and cost. If acetylcysteine is administered, we suggest giving 1200 mg orally twice daily rather than 600 mg twice daily the day before and the day of the procedure.o Based upon the lack of convincing evidence of benefit and ihe potential risk of anaphylactoid reactions, we suggest not using intravenous acetylcysteine for the prevention of contrast nephropathy. (Note: Oral acetylcysteine is used)o We recommend NOT using mannitol or other diuretics prophytactically.o Among patients with stage 3 and 4 CKD, we recommend NOTperforming prophylactic hemofiltration or hemodialysis after contrast exposure.o Among patients with stage 5 CKD, we suggest prophylactic hemodialysis after contrast exposure if there is already a functioning hemodialysis access.
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Paget's disease of bone (PDB) is a common condition characterised by focal areas of increased and disorgan ised bone remodelling. It mostly affects the axial skele ton, and bones that are commonly involved include the pelvis, femur, tibia, lumbar spine, skull and scapula. PATHOPHYSIOLOGY-Diseases of bone The primary abnormality is increased osteoclastic bone resorption, accompanied by marrow fibrosis, increased vascularity of bone and increased osteoblast activity. Bone in PDB is architecturally abnormal and has reduced mechanical strength. Osteoclasts in PDB are increased in number, are unusually large and contain characteristic nuclear inclusion bodies. Genetic factors are impoant and mutations in the SQSTM1 gene are a common cause of classical PDB. The presence of nuclear inclusion bodies in osteoclasts has fuelled speculation that PDB might be caused by a slow virus infection with measles or distemper but the evidence is conflicting. Biomechani cal factors may help determine the pattern of involve ment, since PDB often stas at sites of muscle inseions into bone and, in some cases, localises to bones or limbs that have been subjected to repetitive trauma or overuse. Involvement of subchondral bone can compromise the joint and predispose to OA ('Pagetic ahropathy'). CLINICAL FEATURES -The classic presentation is with bone pain, deformity, deafness and pathological fractures, but many patients are asymptomatic and diagnosed from an abnormal Xray or blood test performed for another reason. Cli nical signs include bone deformity and expansion, increased warmth over affected bones, and pathological fracture. Bone deformity is most evident in weight bearing bones such as the femur and tibia, but when the skull is affected the patient may complain that hats no longer fit due to cranial enlargement. Neurological problems, such as deafness, cranial nerve defects, nerve root pain, spinal cord compression and spinal stenosis, are recognised complications due to enlargement of affected bones and encroachment upon the spinal cord and nerve foraminae. Surprisingly, deafness seldom results from compression of the auditory nerve, but is conductive due to osteosclerosis of the temporal bone. The increased vascularity of Pagetic bone makes opera tive procedures difficult and, in extreme cases, can precipitate highoutput cardiac failure in elderly patients with limited cardiac reserve. Osteosarcoma is a rare but serious complication that presents with subacute onset of increasing pain and swelling of an affected site. INVESTIGATIONS -The characteristic features are an elevated serum ALP and bone expansion on Xray, with alternating areas of radiolucency and osteosclerosis (Fig. 25.57B). ALP is normal in about 5% of cases, usually because of mono stotic involvement. Radionuclide bone scanning is useful to define the presence and extent of disease (Fig. 25.57A). If the bone scan is positive, Xrays should be taken of an affected bone to confirm the diagnosis. Bone biopsy is not usually required but may help to exclude osteo sclerotic metastases in cases of diagnostic unceainty. MANAGEMENT-The main indication for treatment with inhibitors of bone resorption is bone pain thought to be due to increased metabolic activity (Box 25.82). It is often difficult to dif ferentiate this from pain due to complications such as bone deformity, nerve compression symptoms and OA. If there is doubt, it can be wohwhile giving a therapeu tic trial of antiresorptive therapy to determine whether the symptoms improve. A positive response indicates that the pain was due to increased metabolic activity. The aminobisphosphonates pamidronate, zoledronate and risedronate are more effective than simple bisphos phonates such as etidronate and tiludronate at suppress ing bone turnover in PDB, but their effects on pain are similar. Although bisphosphonates suppress bone turn over in PDB, there is no evidence to show that they alter the natural history or prevent complications. Calcitonin can be used as an alternative but is less convenient to administer and more expensive. Repeated courses of bisphosphonates or calcitonin can be given if symptoms recur. If symptoms do not respond to antiresorptive therapy, it is likely that the pain is due to a complication of the disease and this should be managed according to the principles described on page 1085. DAVIDSONS PRINCIPLES AND PRACTICE OF MEDICINE 22ND EDITION PAGE NO-1128,112
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• Although IVU gives excellent images of the urinary tract, its use should be restricted because in a few patients the iodine in the contrast medium may provoke a potentially life-threatening anaphylactic reaction.
• Patients with a history of allergy, atopy and eczema are particularly vulnerable, but severe reactions may occur without warning.
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The child has Hanup's disease. This condition clinically resembles pellagra ("diarrhea, dementia, and dermatitis"), and may be misdiagnosed as this nutritional (niacin) deficiency. In fact, niacin therapy may actually be helpful in controlling the symptoms. The underlying problem is a defect in the epithelial transpo of neutral amino acids, including tryptophan, which can act as a precursor of niacin. The defective amino acid transpo leads to poor absorption of dietary amino acids as well as excess amino acid secretion in the urine. Alkaptonuria is characterized by urine that turns black upon standing and a debilitating ahritis. Carcinoid syndrome is seen in patients with carcinoid tumor. It is characterized by episodes of flushing, diarrhea, hypeension, and bronchoconstriction. Ehlers-Danlos syndrome is a disease characterized by abnormal collagen formation leading to very elastic skin, joint problems, and fragility of some blood vessels and the intestines. Ref: Bender D.A. (2011). Chapter 44. Micronutrients: Vitamins & Minerals. In D.A. Bender, K.M. Botham, P.A. Weil, P.J. Kennelly, R.K. Murray, V.W. Rodwell (Eds),Harper's Illustrated Biochemistry, 29e.
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Acute myelogenous leukemia (AML) infiltrates the marrow and reduces normal hematopoiesis to account for anemia and marked thrombocytopenia. The initial presentation may be acute. The Auer rods are condensations of the azurophilic granules. Dohle bodies, which are patches of dilated endoplasmic reticulum, and toxic granulations, which are coarse and dark primary granules, are reactive changes in mature neutrophils most indicative of marked inflammation, such as bacterial sepsis. Hairy projections are seen on the circulating B cells of hairy cell leukemia. Heinz bodies are seen in G6PD deficiency and are precipitates of denatured globin. Sickling of RBCs is a feature of sickle cell anemia, which is not related to leukemia.
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