UPSC PAPER-1 2002 1. Calcium channel blockers are contraindicated in: A. Acute left ventricular failure B. Essential hypertension C. Peripheral vascular disease D. Primary pulmonary hypertension Ans. A (Harrison 16th ed., p 1441) In acute left ventricular failure calcium channel blockers (e.g., diltiazem) are contraindicated because they decrease the myocardial contractility and further aggravate LVF. In LVF the various drugs used are diuretics, ACE inhibitors, angiotensin receptor blockers, aldosterone antagonist, beta blockers (in selective cases), dopamine, dobutamine, amrinone, morphine etc. In rest of the three conditions calcium channel blockers are used. 2. Which one of the following is not the feature of atrial fibrillation? A. Varying intensity of first heart sound B. Pulse deficit C. Disappearance of presystolic accentuation of mid diastolic murmur D. Prominent ‘a’ wave on JVP Ans. D (Harrison 16th ed., p 1306) In AF ‘a’ wave in JVP is lost. The ‘a’ wave in JVP is produced by venous distention due to contraction of right atrium. In AF the right atrial contraction is chaotic and hence ‘a’ wave is not produced. The first heart sound varies from beat to beat in AF and it is one of the diagnostic features of AF. The pulse deficit (difference between heart rate and pulse rate) is more than 10 in AF. The presystolic accentuation of mid diastolic murmur is mainly due to atrial contraction in MS. Due to loss of proper atrial contraction in MS the presystolic accentuation is lost. Ventricular systole diastole a a c c Jugular v venous pulse y x x Fig.: JVP. 3. Infective endocarditis is a very rare feature of: A. Patent ductus arteriosus B. Osteum secondum atrial septal defect C. Tetralogy of Fallot D. Ventricular septal defect Ans. B (Harrison 16th ed., p 1385) ASD is not associated with endocarditis. Endocarditis occurs when there is a congenital or acquired defect in heart leading to disturbance in blood flow. This leads to a vortex formation or a high pressure jet of blood inside the heart. If bacteraemia occurs the bacteria are caught up in the vortex or are impinged on the defective portion of heart 2002.2 Rapid Digest UPSC – Combined Medical Services Examination (usually valves) due to the high pressure jet of blood. In ASD the defect lies between two relatively low pressure chambers of heart i.e., left and right atrium and hence endocarditis does not occur. 4. Match List-I (Clinical signs) with List-II (Cardiac disease) and select the correct answer using the codes given below the Lists: List-I (Clinical signs) List-II (Cardiac disease) a. Hill’s sign 1. Pericardial effusion b. Ewart’s sign 2. Hypertrophic cardiomyopathy c. Double systolic impulse 3. Junctional rhythm d. Cannon waves 4. Aortic regurgitation Codes: A. a b c d B. a b c d C. a b c d D. a b c d 4 2 1 3 3 1 2 4 4 1 2 3 3 2 1 4 Ans. C Hill’s sign is the popliteal cuff systolic pressure exceeding brachial cuff pressure by more than 60 mm of Hg. This is a peripheral sign of aortic regurgitation. Ewart’s sign is a patch of dullness below the angle of left scapula due to compression of base of left lung by pericardial fluid. Double systolic impulse is often seen in patients suffering from HOCM. Sometimes triple impulse may also be felt. This is due to left ventricular outflow gradient. Cannon wave is giant ‘a’ wave in JVP. This is seen when right atrium contracts against closed tricuspid valve. It is seen in complete heart block, junctional rhythm or AV dissociation with ventricular tachycardia. 5. Match List-I (Type of pulse) with List-II (Cardiac pathology) and select the correct answer using the codes given below the Lists: List-I (Type of pulse) List-II (Cardiac pathology) a. Pulsus parvus 1. Aortic stenosis b. Bisferiens pulse 2. Cardiac tamponade c. Pulsus alternans 3. Aortic stenosis and regurgitation d. Pulsus paradoxus 4. Left ventricular failure Codes: A. a b c d B. a b c d C. a b c d D. a b c d 1 4 3 2 1 3 4 2 2 4 3 1 2 3 4 1 Ans. B (Harrison 16th ed., p 1305) Pulsus parvus is a small weak pulse. It is seen in conditions with decreased left ventricular stroke volume. It is seen in aortic stenosis. Bisferiens pulse has two systolic peaks. It is seen in AR (with or without AS) and HOCM. The first wave is percussion wave and the second wave is tidal wave. Pulsus alternans is seen in LVF. In this type of pulse there is regular alteration of pressure pulse amplitude despite a regular rhythm. This is due to severe LV dysfunction. In pulsus paradoxus the normal decrease in systolic BP during inspiration is exaggerated. The normal fall in systolic BP with inspiration is 10 mmHg. This type of pulse is seen in cardiac tamponade, airway obstruction and superior vena cava obstruction. 6. Consider the following statements: The features of severe asthma include: 1. Central cyanosis 2. Disturbance of consciousness 3. Pulsus paradoxus 4. Heart rate less than 60/minute Which of these statements are correct? A. 2, 3 and 4 B. 1, 3 and 4 C. 1, 2 and 3 D. 1, 2 and 4 Ans. C (Harrison 16th ed., p 1511) In acute bronchial asthma there is severe bronchoconstriction that leads to central cyanosis. UPSC Paper-1 2002 2002.3 In severe cases there may be CO2 narcosis, which leads to altered sensorium. Pulsus paradoxus is also seen in acute cases and it is an indicator of severity of airways obstruction. Tachycardia is observed in bronchial asthma instead of bradycardia. 7. A patient presents with breathlessness. He has bilateral basal crepitations. Lung function tests reveal decrease in total lung capacity (TLC) and vital capacity (VC) with normal FEV1/VC ratio. The most likely diagnosis is: A. Chronic bronchitis B. Idiopathic pulmonary fibrosis C. Cystic fibrosis D. Allergic bronchopulmonary aspergillosis Ans. B (Harrison 16th ed., p 1557) Idiopathic pulmonary fibrosis is a type of interstitial lung disease. In this condition spirometry reveals restrictive defect in the form of decreased TLC, decreased residual functional capacity, residual volume and vital capacity. FEV1/FVC ratio is normal or increased. The diffusion capacity is also decreased. These patients suffer from exertional dyspnoea, nonproductive cough, inspiratory crepitations, clubbing etc. There is no definite treatment that improves the chance of survival. Table: Values of pulmonary physiology (spirometry and lung volumes). Man 40 yr/75 kg Woman 40 yr/60 kg Spirometry Forced vital capacity (FVC) 4.8 L 3.3 L Forced expiratory volume in 1 s (FEV1) 3.8 L 2.8 L FEV1/FVC (FEV1%) 76% 77% Maximal midexpiratory flow (MMF) 4.8 L/S 3.6 L/S Maximal expiratory flow rate (MEFR) 9.4 L/S 6.1 L/S Lung volumes Vital capacity (VC) 1.7 L 1.4 L Residual volume (RV) 1.5 L 1.2 L Functional residual capacity (FRC) 2.2 L 2.6 L Inspiratory capacity (IC) 4.8 L 3.7 L Expiratory reserve volume (ERV) 3.2 L 2.3 L Total lung capacity (TLC) 6.4 L 4.9 L 8. An otherwise healthy young man presented with sudden onset of breathlessness which was increasing rapidly. On examination, it was found that the left chest movement was grossly restricted, breath sounds were absent and tympanitic on percussion. The most likely diagnosis is: A. Tension pneumothorax B. Simple pneumothorax C. Bronchial asthma D. Cardiac asthma Ans. A (Harrison 16th ed., p 1568) The patient is suffering from tension pneumothorax. Absent breath sound with tympanic note on percussion are the main clue for diagnosis. These patients often suffer from chest pain followed by rapidly progressive severe breathlessness. There is high positive pleural pressure and it is a medical emergency. There is shifting of mediastinum to opposite side with decreased or absent breath sound on the side of pneumothorax. The percussion note is tympanic or resonant with obliteration of cardiac or hepatic dullness. A large bore needle should be immediately inserted into pleural cavity in 2nd intercostal space anteriorly. 9. Which one of the following is not correct regarding silicosis? A. Egg shell calcification is seen on chest X-ray B. It is more marked in the lower zone C. May lead to progressive massive fibrosis D. The disease may progress even after the exposure has ceased 2002.4 Rapid Digest UPSC – Combined Medical Services Examination Ans. B (Harrison 16th ed., p 1523) Silicosis is an environmental lung disease due to silica (SiO2) or crystalline quartz. Small rounded opacities appear in the upper lobes with retraction and hilar lymphadenopathy. Calcification of hilar nodes lead to ‘egg shell’ appearance. Gradually there may be progressive massive fibrosis even in absence of further exposure. Patients of silicosis are at great risk of acquiring tuberculosis (silicotuberculosis). Treatment is symptomatic. Remember the following important points commonly asked in examination: 1. Caplan’s syndrome: Seropositive rheumatoid arthritis with progressive massive fibrosis. 2. Byssinosis occurs due to exposure to cotton dust. 3. Siderosis occurs due to exposure to iron oxide. 4. Farmer’s lung: Hypersensitivity pneumonitis due to exposure to moldy hay containing spores of thermophilic actinomycetes. 10. Which one of the following organisms causes pneumonia which most commonly results in pneumatocele? A. Klebsiella pneumoniae B. Haemophilus influenzae C. Staphylococcus aureus D. Streptococcus pneumoniae Ans. C (Nelson 16th ed., p 762-765) Pneumatoceles are seen in Staphylococcus, Group A Streptococcus, Klebsiella, Hemophilus influenzae and primary tuberculous pneumonia with cavitation. Pneumatoceles often persist for several months. CT scan is helpful in confirming its presence. Treatment is rarely required for it. If treatment is required, then surgical removal is to be done. 11. Match List-I (Respiratory sign) with List-II (Clinical condition) and select the correct answer using the codes given below the Lists: List-I (Respiratory sign) List-II (Clinical condition) a. Localized wheeze 1. Pleural effusion b. Shifting dullness 2. Empyema c. Ellis curve 3. Hydropneumothorax d. Intercostal tenderness 4. Bronchial tumour Codes: A. a b c d B. a b c d C. a b c d D. a b c d 2 1 3 4 4 3 1 2 2 3 1 4 4 1 3 2 Ans. B Localized wheeze is seen in bronchial tumour due to obstruction of bronchi. Shifting dullness is seen in hydropneumothorax due to presence of both fluid and air. Presence of air helps in shifting of fluid. Ellis curve is seen in CXR-PA view in pleural effusion. Intercostal tenderness with erythema of overlying skin helps in distinguishing an empyema from simple pleural effusion. Remember: Intercostal tenderness on right side is an important sign of liver abscess also. 12. Which of the following is the primary site of production of gastrin? A. Pylorus B. Antrum C. Pancreas D. Small intestine Ans. B (Harrison 16th ed., p 1748, 1759) Gastrin is secreted from G cells present in pyloric glands, which are situated in gastric antrum. Amino acids and amines in stomach directly stimulate release of gastrin. It in turn activates parietal cells for release of HCl. Remember the following important points commonly asked in examination: 1. Chief cells primarily located in gastric fundus secrete pepsinogen. 2. Pepsin is active at pH < 2.0. 3. Intrinsic factor is secreted by parietal cells. UPSC Paper-1 2002 2002.5 4. Prostaglandins play a central role in gastric epithelial defence/repair. 5. Primary bile acids: Cholic acid and chenodeoxycholic acid (synthesised from cholesterol). 6. Secondary bile acids: Deoxycholate and lithocholic acid. 7. CCK stimulates increased output of pancreatic enzymes. 8. Secretin leads to increased output of pancreatic juice and HCO3–. 13. Chronic active hepatitis is more reliably distinguished from chronic persistant hepatitis by the presence of: A. Extrahepatic manifestation B. Significant titre of antismooth muscle antibody C. Characteristic liver histology D. Hepatitis B surface antigen Ans. C (Harrison 15th ed., p 1743; 16th ed., p 1845) Histopathological study of liver is the best way to distinguish between chronic active hepatitis and chronic persistent hepatitis. In chronic persistent hepatitis mononuclear inflammatory infiltrates are localized to and contained within portal tracts. The limiting plate of periportal hepatocytes is intact and there is no extension into liver lobule. Cobblestone appearance is present and cirrhosis is absent. Minimal periportal fibrosis may be seen. In chronic active hepatitis there is continuing hepatic necrosis, portal/periportal and to a lesser extent lobular inflammation. Fibrosis is present. Mononuclear infiltrates extend into liver lobule. The limiting plate is eroded with destruction of hepatocytes. Piecemeal necrosis is present and is important for diagnosis. In severe cases bridging hepatic necrosis is seen. There is collapse of reticulin network. 14. Commonest early symptom of primary biliary cirrhosis is: A. Pruritus B. Jaundice C. Hepatomegaly D. Pale stools Ans. A (Harrison 16th ed., p 1860) Primary billiary cirrhosis is a disease of unknown aetiology. It is often associated with autoimmune disorders. Circulating IgG antimitochondrial antibody is present in 90% of cases. 90% of patients are women of age 35-60 years. The commonest early feature is pruritus, which may be generalized or localized to palm and soles. Fatigue is another common early feature. Gradually jaundice, xanthalesmas, hyperpigmentation develops. Portal hypertension may develop later. Serum alkaline phosphatase is raised. Hyperlipidaemia is common. Serum unesterified cholesterol is elevated. 15. Which one of the following is not used as a criteria in the Child-Pugh classification of liver disease to identify the risk categories? A. Serum albumin B. SGOT, SGPT ratio C. Ascites D. Prothrombin time Ans. B (Harrison 16th ed., p 1813) Child-Pugh classification initially was used to stratify patients into risk groups before portal decompressive surgery but now it is used to assess prognosis in cirrhosis. SGOT, SGPT ratio is not used in this classification. In this scoring system score ranges from 5 to 15, score of 5 to 6 being Child-Pugh class A, scores 7 to 9 is Child- Pugh class B and score of 10 to 15 is class C. Table: Child-Pugh classification of cirrhosis. Factor Units 1 2 3 Serum bilirubin μmol/L < 34 34-51 > 51 mg/dL < 2.0 2.0-3.0 > 3.0 Serum albumin g/L > 35 30-35 < 30 g/dL > 3.5 3.0-3.5 < 3.0 Prothrombin time Second 0-4 4-6 >6 INR < 1.7 1.7-2.3 > 2.3 Ascites None Easily controlled Poorly controlled Hepatic encephalopathy None Minimal Advanced 2002.6 Rapid Digest UPSC – Combined Medical Services Examination 16. Consider the following statements: Cystic fibrosis of the pancreas: 1. Is an autosomal dominant disorder 2. Is established by sweat sodium concentrations more than 80 mmol/l 3. May produce neonatal small bowel obstruction 4. Is associated with a dysfunction of all mucus secreting glands Which of these statements are correct: A. 2, 3 and 4 B. 1, 3 and 4 C. 1, 2 and 3 D. 1, 2 and 4 Ans. A (Harrison 16th ed., p 1543) Cystic fibrosis is an autosomal recessive disease. It is due to mutation in gene located in chromosome 7. There is a 3-bp deletion that results in absence of phenylalanine at amino acid position 508 of the gene product known as cystic fibrosis transmembrane regulator. This is normally found in plasma membrane in normal epithelia. It acts as a cyclic AMP regulated Cl– channel across the ductal epithelial cells. Patients are not able to absorb NaCl from sweat as it moves through the sweat duct due to inability to absorb Cl– across the ductal epithelial cells. Neonates suffer from meconium ileus. The patients present with abdominal distention, vomiting and failure to pass stool. 17. The persons working in dye industry are prone to develop malignancy of: A. Kidney B. Urinary bladder C. Prostate D. Lung Ans. B (Harrison 16th ed., p 539) Exposure to aniline dye leads to development of cancer of urinary bladder. The other factors that lead to bladder CA are cigarette smoking, phenacetin, chlornaphzine, external beam radiation, cyclophosphamide, diet rich in meat and fat, Schistosoma hematobium etc. 18. Which one of the following is not true regarding pseudobulbar palsy? A. Emotional incontinence B. Exaggerated jaw jerk C. Dysarthria D. Flaccid tongue Ans. D (Harrison 16th ed., p 134) Bilateral corticobulbar lesion leads to pseudobulbar palsy. There is dysphagia, dysphonia, dysarthria, and emotional lability with bilateral facial weakness. Pseudobulbar palsy is an upper motor neuron lesion and hence flaccid tongue is absent. Tongue will be spastic. Remember: Bulbar palsy is lower motor neuron lesion and in this condition the tongue will be flaccid. 19. Hypokalemia is caused by the following except: A. Cushing’s syndrome B. Conn’s syndrome C. Bartter’s syndrome D. Addision’s disease Ans. D (Harrison 16th ed., p 261) Hypokalaemia is defined as serum K+ < 3.5 mmol/l. In Addison’s disease due to lack of glucocorticoid, hyperkalaemia is seen. In Cushing’s syndrome there is excess of glucocorticoid, which promotes K+ excretion in urine leading to hypokalaemia. In Conn’s syndrome there is excess mineralocorticoid, which in turn leads to excess K+ wastage in urine. Bartter’s syndrome is characterized by hypokalaemia, metabolic alkalosis, hyperreninaemic hyperaldosteronism secondary to ECF volume contraction and juxtaglomerular apparatus hyperplasia. UPSC Paper-1 2002 2002.7 Table: Causes of hypokalemia. I. Decreased intake: a. Starvation. b. Clay ingestion. II. Redistribution into cells: a. Acid-base: 1. Metabolic alkalosis b. Hormonal: 1. Insulin 2. β2-Adrenergic agonists (endogenous or exogenous). 3. α-Adrenergic antagonists. c. Anabolic state: 1. Vitamin B12 or folic acid (red blood cell production). 2. Granulocyte-macrophage colony stimulating factor (white blood cell production). 3. Total parenteral nutrition. d. Other: 1. Pseudohypokalemia. 2. Hypothermia. 3. Hypokalemic periodic paralysis. 4. Barium toxicity. III. Increased loss: a. Nonrenal: 1. Gastrointestinal loss (diarrhea). 2. Integumentary loss (sweat). b. Renal: 1. Increased distal flow: Diuretics, osmotic diuresis, salt-wasting nephropathies. 2. Increased secretion of potassium: i. Mineralocorticoid excess: Primary hyperaldosteronism, secondary hyperaldosteronism (malignant hypertension, renin-secreting tumors, renal artery stenosis, hypovolemia), apparent mineralocorticoid excess (licorice, chewing tobacco, carbenoxolone), congenital adrenal hyperplasia, Cushing’s syndrome, Bartter’s syndrome. ii. Distal delivery of non-reabsorbed anions: Vomiting, nasogastric suction, proximal (type 2) renal tubular acidosis, diabetic ketoacidosis, glue-sniffing (toluene abuse), penicillin derivatives. iii. Other: Amphotericin B, Liddle’s syndrome, hypomagnesemia. 20. Sensorineural deafness associated with hereditary nephritis is seen in: A. Fanconi’s syndrome B. Berger’s disease C. Albright’s syndrome D. Alport’s syndrome Ans. D (Harrison 16th ed., p 2331) Alport’s syndrome is X-linked dominant disease. It is the commonest cause of hereditary nephritis. The defect lies in the gene for α5 chain of type IV collagen located in long arm of X chromosome. Males usually present with microscopic haematuria with proteinuria and progressive renal insufficiency. The extrarenal features are sensorineural hearing loss (60%), bilateral anterior lenticonus (15 to 30%) and recurrent corneal erosion. Female carriers usually have mild disease and do not suffer from renal insufficiency. 21. Metabolic acidosis with increased anion gap occurs in all of the following except: A. Diabetic ketoacidosis B. Lactic acidosis C. Renal tubular acidosis D. Methanol poisoning Ans. C (Harrison 16th ed., p 265) See answer of question 50 of paper 1 UPSC 2003 for description of anion gap. In renal tubular acidosis anion gap is normal. 2002.8 Rapid Digest UPSC – Combined Medical Services Examination Table: Causes of high and non anion-gap acidosis. Causes High anion-gap metabolic acidosis Diabetic, alcoholic and starvation ketoacidosis, lactic acidosis, ethylene glycol, methanol, salicylates, ARF, CRF Non anion-gap acidosis Diarrhoea, ureterosigmoidostomy, small bowel fistula, renal tubular acidosis, drug induced hyperkalaemia (spironolactone, ACE inhibitors, NSAID, cyclosporin), cation exchange resins, rapid saline administration, hyperalimentation 22. The following conditions may present with both upper and lower motor neuron involvement except: A. Subacute combined degeneration of spinal cord B. Friedreich’s ataxia C. Amyotrophic lateral sclerosis D. Becker’s dystrophy Ans. D (Harrison 16th ed., p 2529) Becker’s muscular dystrophy is the less severe form of X-linked recessive muscular dystrophy that results from allelic defect of the same gene responsible for Duchenne dystrophy. It is basically a disease of muscle and upper and lower motor neuron features in combination are absent. Proximal muscles mainly of lower extremities are involved. Hypertrophy of calves is an early feature. These patients are able to walk beyond 15 years of age whereas patients with Duchenne dystrophy are not able to walk by age 12. Subacute combined degeneration of cord is due to vitamin B12 deficiency. The spinal cord as well as peripheral nerves are involved. This results in progressive spastic and ataxic weakness with loss of tendon jerks. Amyotrophic lateral sclerosis is the commonest motor neuron disease. It involves both the upper and the lower motor neurons. The sensory system, the bowel, bladder function and ocular motility remains intact. Friedreich’s ataxia is the commonest inherited ataxia. Spinal cord, dorsal root ganglion cells and peripheral nerves are involved. Extensor plantar with absence of tendon jerks and loss of power is commonly observed. 23. The characteristic feature of Horner’s syndrome is: A. Dilated pupil B. Ptosis C. Increased sweating D. Abducted eye Ans. B (Harrison 15th ed., p 2377) Horner’s syndrome is due to paralysis of the cervical sympathetic nerve. The sympathetic nerve fibres supplying the pupil originate on the lower cervical and upper thoracic regions of the spinal cord – C8 and T1. Horner’s syndrome consists of slight drooping of upper lid (ptosis), miosis, absence of pupillary dilatation on shading the eye or instillation of cocaine, abolition of ciliospinal reflex. Less commonly absence of sweating on corresponding half and enophthalmos. A Holmes-Adie pupil (Right) B Homer’s syndrome (Right) C Argyll Robertson pupils with bilateral ptosis and small, irregular pupils Fig.: Abnormalities of pupil. UPSC Paper-1 2002 2002.9 24. Which one of the following conditions is not true regarding myotonic dystrophy? A. Cardiac defects B. Cataract C. Frontal baldness D. Enlarged testis Ans. D (Harrison 16th ed., p 2530) Myotonic dystrophy is the commonest adult muscular dystrophy. Testicular enlargement is absent in myotonic dystrophy. Gonadal atrophy is seen in these patients. Remember the clinical features, which are frequently asked in various entrance examinations: Clinical features: hatchet-faced appearance, weakness of distal muscles of extremities (proximal muscles remain stronger), dysarthria, nasal voice, myotonia (slow relaxation of hand grip), cardiac defects (heart block, sudden death, MVPS), intellectual impairment, hypersomnia, posterior sub capsular cataract, frontal baldness etc. 25. Homonymous hemianopia may occur due to lesion involving: A. Optic nerve B. Optic chiasma C. Optic tract D. Bilateral foveal lesions Ans. C (Harrison 16th ed., p 164) Whenever there is lesion of optic tract, lateral geniculate body, optic radiation or visual cortex there is homonymous hemianopia. Homonymous hemianopia means loss of one half of visual field either left or right. Visual field defects Visual fields L R Left eye Right eye 1. Total loss of vision in one eye owing to lesion of 1 the optic nerve (left side). 2. Bitemporal hemianopia due to compression of Retina 2 the optic chiasma. Optic nerve 3. Right homonymous hemianopia from lesion of the optic tract (left side). 3 Optic chiasma Optic tract 4. Upper right quadrantic hemianopia from a lesion of the lower fibres of the optic radiation in the 4 Lateral geniculate body temporal lobe (left side). Optic radiation 5. Lower quadrantic hemianopia occurs from a 5 Lower fibres in temporal lobe lesion of the upper fibres of the optic radiation (Meyer's loop)* in the anterior part of the parietal lobe (left side). Upper fibres in anterior 6 parietal lobe 6. Right homonymous hemianopia with sparing of the macula from a lesion of the optic radia- All fibres in posterior tion in the posterior part of the parietal lobe (left side). parietal lobe Primary visual cortex Fig.: Visual field defects. 26. Uncontrolled action of which of the following enzymes plays a major etiological role in chronic myeloid leukemia? A. Tyrosine kinase B. Cholinesterase C. Galactokinase D. Bradykinin Ans. A (Harrison 16th ed., p 637) CML is characterized by presence of fusion gene resulting from t(9:22) translocation called ‘Philadelphia chromosome’. The translocation results in head to tail fusion of breakpoint cluster region (BCR) gene on chromosome 22q11 with the ABL gene located in chromosome 9q34. The product of fusion gene promotes development of CML. The ABL protein becomes active as tyrosine kinase enzyme. Remember the following important points commonly asked in examination: 1. Radiation is a risk factor for CML. 2. Fatigue, malaise, weight loss and splenomegaly are important presenting features. 3. Leucocyte alkaline phosphatase is characteristically low in CML. 2002.10 Rapid Digest UPSC – Combined Medical Services Examination 4. Serum B12 and B12 binding proteins are elevated. 5. Basophilia, eosinophilia, monocytosis and thrombocytosis may be seen with raised total leucocyte count. 6. In blast crisis blood or marrow blasts are ≥ 20%. Hyposegmented neutrophil (Pelger-Huet abnormality) may be seen. 7. Allogenic HLA compatible stem cell transplantation is the treatment of choice. 8. If transplantation is not possible then imatinib mesylate is the treatment of choice. 27. Which of the following blood group antigens serves as receptor for Plasmodium vivax? A. Duffy B. ABO C. Kell D. Rh Ans. A (Harrison 16th ed., p 1219) The RBC receptor for P. vivax is related to Duffy blood group antigen Fya or Fyb. Most West African people carry Duffy negative FyFy phenotype and hence are resistant to P. vivax. 28. Consider the following statements: Factor VIII (AHF) is involved in coagulation mechanism of haemostasis: 1. Only in extrinsic pathway 2. Only in intrinsic pathway 3. In common pathway Which of these statements is/are correct? A. 1 only B. 2 only C. 1 and 3 D. 2 and 3 Ans. B (Harrison 16th ed., p 680) Factor VIII is antihaemophilic factor that regulates the activation of factor X by proteases generated in the intrinsic coagulation pathway. It is synthesized in liver and circulates complexed to the von Willebrand factor. The gene for factor VIII is located in X-chromosome. Intrinsic system HMW kininogen Kallikrein XII XIIa HMW kininogen Extrinsic system XI XIa TPL IXa VIIa VII IX 2+ PL PL Ca 2+ VIII VIIIa Ca , TPL X Xa 2+ PL Ca V Va II Thrombin Fibrinogen Fibrin XIII XIIIa Stabilisation Fig.: Extrinsic and intrinsic mechanism of clotting. (PL-platelet phospholipid, HMW-high molecular weight, α-activated form, TPL-tissue thromboplastin). 29. Which one of the following is not associated with hyperkalemia? A. Tall T waves B. Pronged QRS interval C. Short PR interval D. Sine waves UPSC Paper-1 2002 2002.11 Ans. C (Harrison 16th ed., p 1318; Bedside Interpretation of ECG – A Practical Approach 1st ed., TK Koley 1st ed., p 143) In hyperkalaemia ‘P’ wave becomes absent gradually. P-R interval may be prolonged before disappearance of P wave. Tall and tented ‘T’ waves are seen in early phase of hyperkalaemia. QRS interval gradually increases and later takes the sine wave pattern. Sine wave is seen in severe hyperkalaemia. Short P-R interval is seen in WPW syndrome. Fig.: ECG showing hyperkalaemia. Note the wide QRS complexes and tall T waves. At this time the serum potassium was 9.1 mEq/l. 30. Consider the following statements: In nephrogenic diabetes insipidus the patient is likely to have: 1. High vasopressin level 2. Poor or no response to desmopressin 3. Low plasma osmolality 4. Elevated plasma glucose level Which of these statements are correct? A. 1, 2 and 3 B. 2, 3 and 4 C. 1 and 4 D. 1, 2, 3 and 4 Ans. A (Harrison 15th ed., p 2055; 16th ed., p 2098-2100) Elevated plasma glucose is a feature of diabetes mellitus. Plasma glucose is normal in diabetes insipidus. Remember the following important points commonly asked in examination: 1. In nephrogenic diabetes insipidus there is defect in action of AVP, which may be genetic, acquired or caused by exposure to various drugs. The genetic form (X-linked) is caused by mutation of coding region of V2 receptor gene. 2. The secretion of AVP is normal. The level of AVP may be high as well especially during modest fluid restriction. 3. Desmopressin is active in central diabetes insipidus where AVP level is low. In nephrogenic diabetes insipidus desmopressin is inactive. 4. In diabetes insipidus the urine volume is > 50 ml/kg body weight and the osmolality is < 300 mmol/kg. 31. Lymphogranuloma venereum is best treated by: A. Doxycycline B. Erythromycin C. Azithromycin D. Ciprofloxacin Ans. C (Harrison 16th ed., p 1016) Lymphogranuloma venereum is caused by C. trachomatis. It is a STD. Usually it manifests as genital ulcer. Inguinal lymphadenopathy is common. It may produce ‘sign of groove’ i.e., the lymph nodes above and below the inguinal ligament are enlarged. 2002.12 Rapid Digest UPSC – Combined Medical Services Examination Tetracycline or doxycycline was used for management till the introduction of azithromycin. 1 g single dose azithromycin is equivalent to 7 days doxycycline therapy. 32. Among the following groups, which combination is not useful for the treatment of hypertension? A. Atenolol with amlodipine B. Enalapril with hydrochlorthiazide C. Alpha methyldopa with clonidine D. Amlodipine with lisinopril Ans. C Alpha methyldopa and clonidine are centrally acting antihypertensive drugs. Both of them are rarely used as single drug in management of hypertension because of availability of better drugs. The combination of two drugs with similar mechanism of action has no rationale in management of hypertension. Hence alpha methyldopa and clonidine together is not useful in treating hypertension. 33. Consider the following: 1. Metolazone 2. Amiloride 3. Triamterene 4. Chlorthalidone Which of the above are the potassium sparing diuretics? A. 1, 2 and 3 B. 1, 2 and 4 C. 2 and 3 D. 1, 3 and 4 Ans. C (Harrison 16th ed., p 1373-1374) Spironolactone, amiloride and triamterene are potassium-sparing diuretics. They are contraindicated in renal failure. Metolazone is a quinethazone derivative and has a site of action and potency similar to thiazides. Chlorthalidone belongs to the thiazide group of diuretics. It is administered once daily. 34. Which one of the following features may not be seen in hypothyroidism? A. Cold intolerance B. Deafness C. Pericardial effusion D. Pretibial myxoedema Ans. D (Harrison 16th ed., p 2115) Pretibial myxoedema is a feature of thyrotoxicosis. The cause of it is unknown. It is characterised by nonpitting peau d' orange appearance of skin of lower limbs. Growth retardation, menorrhagia, carpal tunnel syndrome, constipation, cold intolerance etc are features of hypothyroidism. 35. Lactic acidosis is more likely to be caused by: A. Gliclazide B. Acarbose C. Metformin D. Pioglitazone Ans. C (Harrison 16th ed., p 266) There are two types of lactic acidosis type A and type B. Type A occurs due to tissue hypoxia and the commonest cause is cardiogenic shock or sepsis. Type B occurs in metabolic abnormality or is drug induced. The various causes of lactic acidosis are poisoning (ethylene glycol, methanol), insulin deficiency, biguanides administration, hepatic failure, malignancy, jejunoileal bypass operation, etc. 36. Consider the following statements: In acromegaly, the patient is likely to have: 1. Impaired glucose tolerance 2. Galactorrhoea 3. Hypertension 4. Suppression of growth hormone with glucose Which of these statements are correct? A. 1, 2 and 4 B. 2, 3 and 4 C. 1, 3 and 4 D. 1, 2 and 3 Ans. D (Harrison 16th ed., p 2090) Acromegaly is due to excessive secretion of GH in adult from pituitary adenoma. The clinical features are frontal bossing, increased hand and foot size, prognathism, increased heal pad thickness, hyperhidrosis, hollow voice, kyphosis, arthropathy, oily skin, muscle weakness, fatigue, skin tags, cardiomegaly, thyromegaly etc. Hypertension (30%), galactorrhoea and impaired glucose tolerance are also observed. UPSC Paper-1 2002 2002.13 The diagnosis of acromegaly is confirmed by failure of GH suppression to <1 µg/L within 1 to 2 hr of 75 g oral glucose. 20% of patients may show paradoxical rise. 37. The following are the known complications of mumps except: A. Orchitis B. Pancreatitis C. Aseptic meningitis D. Bilateral arthritis Ans. D (Harrison 16th ed., p 1154) Mumps is probably the commonest cause of aseptic meningitis in children. Orchitis is frequent in adolescents but not common in children. Pancreatitis is also a frequent complication. The other complications of mumps are meningoencephalitis, oophoritis, nephritis, myocarditis, thyroiditis, mastitis, deafness, arthritis etc. 38. Mycobacterium leprae grow well in: A. Cat B. Dog C. Armadillo D. Platypus Ans. C (Harrison 16th ed., p 967) M. leprae mainly infects human being however in Texas and Louisiana, 15% of nine-branded armadillos are infected. Following experimental IV inoculation of M. leprae, 60% of armadillos develop infection in liver, spleen, lymph nodes and skin. M. leprae also grows in foot pad of mice. 39. Consider the following statements about viruses: 1. Viruses may infect bacteria also 2. Picorna viruses are composed of only RNA and protein 3. Rabies virus belongs to rhabdovirus family 4. Epstein Barr virus causes infectious mononucleosis Which of these statements are correct? A. 1, 2 and 3 B. 2 and 3 C. 1 and 4 D. 1, 2, 3 and 4 Ans. D Viruses may infect bacteria – these are called bacteriophages. Picornavirus contains RNA and protein. Important members are poliovirus, coxsackievirus, echovirus, enterovirus, rhinovirus, hepatitis A virus etc. Rabies virus and vesicular stomatitis virus belong to rhabdovirus family. Epstein Barr virus causes infectious mononucleosis, Burkitt’s lymphoma etc. It is also associated with nasopharyngeal CA, mixed cellularity Hodgkin’s lymphoma, AIDS etc. 40. Consider the following statements about rickettsial diseases: 1. These are transmitted by arthropod vectors 2. Eschar is not seen in Rocky Mountain spotted fever 3. Weil-Felix reaction may be diagnostic 4. Cephalosporins are the drug of choice Which of these statements are correct? A. 1, 2 and 3 B. 2, 3 and 4 C. 1, 3 and 4 D. 1, 2 and 4 Ans. A (Harrison 16th ed., p 999) Rickettsial diseases are transmitted by various types of arthropod vector for e.g., ticks. Eschar is seen at the site of bite in Mediterranean spotted fever, rickettsial pox and scrub typhus. Weil Felix reaction is not of much use now because of better available investigation e.g., indirect immunofluorescence assay. Previously it was used for diagnosis. The drug of choice for rickettsial diseases is doxycycline. Ciprofloxacin and chloramphenicol are also used but cephalosporin has no role. 41. A 30-year old male presents with severe bladder irritation, persistent pyuria, microscopic hematuria and absence of bacteria in usual smears and culture. What is the probable diagnosis? A. Monilial infection B. Lower urinary tract obstruction C. Vesical calculus D. Genito-urinary tuberculosis Ans. D (Harrison 16th ed., p 958) 2002.14 Rapid Digest UPSC – Combined Medical Services Examination Culture negative pyuria (sterile pyuria) in acidic urine indicates tuberculosis. Genitourinary tuberculosis accounts for about 15% of all extra pulmonary tuberculosis. Increased urinary frequency, dysuria, haematuria and flank pain are common presentation. Patient may be asymptomatic. However pyuria is persistent and ordinary smear examination may not reveal any organism. 42. Consider the following serological tests: 1. Treponoma pallidum immobilization test (TPI) 2. T. pallidum haemagglutination assay (TPHA) 3. Fluorescent treponomal antibody absorbed test (FTA-ABS) 4. Venereal Disease Research Laboratory test (VDRL) Which of these are specific for diagnosing syphilis? A. 1 only B. 2 and 4 C. 3 and 4 D. 1, 2 and 3 Ans. D (Harrison 16th ed., p 982; Ananthanarayan and Paniker Microbiology 6th ed., p 353) Treponema pallidum haemagglutination assay (TPHA) and fluorescent treponema antibodies absorbed tests (FTA-ABS) are very specific and are used for confirmation of positive non-treponemal tests. TPHA and FTA- ABS have a very high positive predictive value for diagnosis of syphilis. In past, Treponema pallidum immobilization (TPI) was the most specific test for diagnosis of syphilis and was considered gold standard in syphilis serology. TPI has now been supplemented by other tests such as FTA-ABS and TPHA, which are equally specific and much simpler. Remember the following important points about serology of syphilis: 1. First of reagin antibody test used was Wassermann complement fixation test. 2. First flocculation test used was tube flocculation test of Kahn. 3. VDRL test for syphilis is an example of slide flocculation test. 4. Although T. pallidum can cross placenta at any stage of pregnancy but T. pallidum enters the fetal circulation after 20th week with disappearance of Langhans layer (cytotrophoblast) in the villi. 5. For measurement of IgM in neonates for diagnosis of congenital syphilis, Capila M-test and 19 S IgM FTA-ABS tests are available. 6. Testing of large numbers of sera for screening or diagnostic purposes, reagin antibody tests like VDRL or RPR are used. 7. Quantitative measurements of antibody titre to assess the clinical activity of syphilis or for monitoring the response to therapy, tests used are VDRL or RPR-test. 8. Confirmation of the diagnosis of syphilis in a patient with positive non treponemal antibody test or with a suspected clinical diagnosis of syphilis is by FTA-ABS test or Serodia TP-PA. Table: Causes of false-positive reaction in non treponemal serological tests for syphilis. Acute false positive reaction (< than 6 months) Chronic false positive (> 6 months) Recent viral illness or immunization Aging Genital herpes Autoimmune disorder HIV infection SLE Malaria Rheumatoid arthritis Parenteral drug use Parenteral drug use 43. Which one of the following parasites may cause suppurative cholangitis? A. Ankylostoma duodenale B. Ascaris lumbricoides C. Necator americanus D. Trichuris trichura Ans. B (Harrison 15th ed., p 1234; 16th ed., p 1257) Large worms of Ascaris lumbricoides can enter and occlude the biliary tree causing biliary colic, cholangitis, pancreatitis or rarely intrahepatic abscesses. Ascaris lumbricoides is the largest intestinal nematode parasite of man and can reach up to 40 cm. A. lumbricoides is transmitted by swallowing of infective eggs. UPSC Paper-1 2002 2002.15 44. Match List-I (Nutrient excess or deficiency) with List-II (Clinical effects) and select the correct answer using the codes given below the Lists: List-I (Nutrient excess or deficiency) List-II (Clinical effects) a. Copper 1. Eczematous dermatitis around nose and mouth b. Iron 2. Diabetes mellitus c. Zinc 3. Increased density of bone d. Fluoride 4. Chronic liver disease Codes: A. a b c d B. a b c d C. a b c d D. a b c d 4 2 1 3 3 2 1 4 4 1 2 3 3 1 2 4 Ans. A Copper toxicity results in nausea, vomiting, hepatic failure, haemolytic anaemia, renal dysfunction, mental deterioration etc. Iron excess leads to haemachromatosis. In this condition diabetes may develop which is known as bronze diabetes. Zinc deficiency is associated with growth retardation, alopecia, dermatitis, diarrhoea, gonadal atrophy, impaired spermatogenesis etc. Excess fluoride in diet/water leads to fluorosis. There is increased density of bones but they become brittle. 45. Low serum sodium with normal serum osmolality is a feature of: A. Primary polydipsia B. Diuretic use C. Hyperlipidemia D. Hypoaldosteronism Ans. C (Harrison 16th ed., p 255) Hyperlipidaemia and hyperproteinaemia are two conditions in which there is hyponatraemia with normal plasma osmolality. This is also called pseudohyponatraemia. Since Na+ ions are dissolved in plasma water, increasing the nonaqueous phase lowers the Na+ concentration. Hyponatraemia with raised plasma osmolality is seen in hyperglycaemia and mannitol therapy. Hypoosmolal hyponatraemia is seen in primary polydipsia, diuretic use and hypoaldosteronism. 46. Dyslipidaemia with raised triglyceride and low HDL cholesterol is seen in all of the following conditions except: A. Uncontrolled diabetes mellitus B. Hypertensive on beta blocker therapy C. Regular alcohol consumption D. Obesity with BMI more than 30 Ans. C (Harrison 15th ed., p 2253) Ethanol increases level of NADH in the liver, which stimulates synthesis of fatty acids and their incorporation in triglycerides. Hence hypertriglyceridaemia occurs but it also stimulates the synthesis of apo A1 and inhibits cholesteryl ester transfer protein (CETP) that results in normal or elevated levels of HDL cholesterol. 47. Healing with calcification is a feature of: A. Cryptococcosis B. Mucormycosis C. Aspergillosis D. Histoplasmosis Ans. D (Harrison 16th ed., p 1179) Histoplasma capsulatum is a dimorphic fungus. It causes granulomatous infection with caseation necrosis. Calcification is a common finding and the features resemble tuberculosis. Calcification may be seen in lungs or hilar lymph nodes. Remember the following important points commonly asked in examination: 1. Histoplasmosis mimics pulmonary tuberculosis. 2. Histoplasmoma: Rounded mass of scar tissue with or without central calcification in lungs. 3. Pigeon droppings spread cryptococcosis. 4. C. neoformans causes meningoencephalitis in AIDS. 5. Rhinocerebral mucormycosis occurs in immunosupressed conditions like diabetes mellitus, post organ transplant, malignancy etc. 2002.16 Rapid Digest UPSC – Combined Medical Services Examination 48. Name the target structure in skin involved in acne vulgaris: A. Sebaceous glands B. Bartholin glands C. Sweat glands D. Hair follicles Ans. A (Harrison 16th ed., p 294) Acne vulgaris is caused by overproduction of sebum by sebaceous glands after puberty. Small cysts, called comedones are formed in hair follicles due to blockage of follicular orifice by retention of sebum and keratinous material. Remember the other important points about acne: 1. Clinical hallmark of acne vulgaris is comedone. 2. Severe nodulocystic acne is not responsive to oral antibiotics, hormone therapy or topical therapy. May be treated with the synthetic retinoid, isotretinoin, 0.5 to 2.0 mg/kg as single daily dose for 15 to 20 days. 3. Isotretinoin is avoided during pregnancy due to high teratogenic potential. Up to 25% foetuses had birth defects – craniofacial, heart and CNS abnormalities (ACCUTANE embryopathy). 4. Acne rosacea particularly affects central face only, rarely central chest and back. 5. Rosacea of very long duration may lead to connective tissue overgrowth, particularly of nose (rhinophyma). 6. Fluorinated glucocorticoids should be avoided since chronic use of these preparations may actually elicit rosacea. 7. Ice pick scars are typical of acne lesions. 49. On radiological investigation, ‘bamboo spine’ is typically seen in: A. Reiter’s syndrome B. Ankylosing spondylitis C. Psoriatic arthritis D. Gout Ans. B (Harrison 16th ed., p 1993) In ankylosing spondylitis the outer annular fibres of disc cartilage are eroded and finally replaced by bone, forming a bony excrescence called syndesmophyte, which then grows by enchondral ossification that ultimately bridges the adjacent vertebral bodies. This finding when involves a length of spine is seen radiologically as bamboo spine. Some other lesions seen are osteoporosis, erosion of vertebral bodies at the disc margin, squaring of vertebral bodies. Initial changes involve the sacroiliac joints, followed by thoracolumbar and lumbosacral region. Involvement of sacroiliac joint is asymmetrical early but becomes bilateral symmetrical. Appendicular skeleton joints may be involved, most frequently hips and shoulders. There is asymmetrical involvement. 50. Consider the following statements regarding classic polyarteritis nodosa: 1. It is multi-system necrotising vasculitis 2. Small and medium vessels are involved 3. Pulmonary artery involvement is a characteristic feature 4. Up to 30% patients may test positive for hepatitis B surface antigen Which of these statements are correct? A. 1 and 2 B. 2 and 3 C. 1, 2 and 4 D. 2, 3 and 4 Ans. C (Harrison 16th ed., p 2007) PAN is a medium-sized blood vessel vasculitis. It commonly affects middle aged men. Pulmonary arteries are not involved in PAN and bronchial artery involvement is uncommon. Kidney, heart, muscles , GIT, skin, nervous system are commonly involved in PAN. Hepatitis B antigen is present in 20 to 30% of patients particularly the classic PAN type. Hepatitis C infection is reported in about 5% of patients with PAN. 51. A patient on haloperidol for psychosis develops fever, altered sensorium and labile hypertension. Drug useful in treating this patient is: A. Cefotaxime B. Bromocriptine C. Largactil D. Propranolol Ans. B (Harrison 15th ed., p 2405; 16th ed., p 2418) UPSC Paper-1 2002 2002.17 Haloperidol toxicity leads to neuroleptic malignant syndrome. There is rigidity, hyperthermia, altered mental status that resembles catatonia, labile blood pressure and autonomic dysfunction. Treatment is with dantrolene, bromocriptine, levodopa, amantadine etc. Mortality is 5-20%. 52. Which of the following types of schizophrenia carries a bad prognosis? A. Paranoid B. Catatonic C. Hebephrenic D. Undifferentiated Ans. C (Niraj Ahuja 5th ed., p 55) Hebephrenic schizophrenia carries bad prognosis. Hebephrenic schizophrenia has one of the worst prognosis among the subtypes of schizophrenia. The onset of hebephrenic schizophrenia is insidious, usually in the early 2nd decade. The course is progressive. The recovery from episode classically never occurs. In addition to the general features of schizophrenia it is characterized by marked thought disorder, mannerisms, mirror gazing, marked impairment of social and occupational functioning, delusions and hallucinations which are fragmentary and changeable. 53. A 30-year old male complains of infertility. He appears tall and has gynaecomastia. Genitalia appear normal except for bilateral small testes. His chromosomal pattern is likely to be: A. 45 XO B. 47 XXY C. 47 XYY D. 46 XY Ans. B (Harrison 16th ed., p 2215) The patient is suffering from Klinefelter’s syndrome (47, XXY). Klinefelter syndrome (47, XXY) is the commonest disorder of sexual differentiation. The features are tall stature, small and firm testes, azoospermia, gynaecomastia and elevated gonadotropins in men. The increased height is due to longer legs. Short stature is seen in Turner's syndrome (45, XO), achondroplasia and Down’s syndrome (trisomy 21). Table: Disorders of sex chromosome. Disorder Chromosomal External Internal Gonadal Breast Comment complement genitalia genitalia development develomment Turner syndrome 45, X or Immature Hypoplastic Streak Immature Short stature, webbing of 46, XX/45,X female female gonads female neck, low hairline, shield like chest with widely spaced nipples, growth retardation Klinefelter 47, XXY or Normal Normal Hyalinized Gynaecomastia Commonest disorder of syndrome 46, XY/47 XXY male male testis sexual differentiation, tall stature, risk of breast CA 20 times that of normal men, diabetes mellitus, pituitary and thyroid disor- der common XX male 46, XX Normal Normal Hyalinized Gynaecomastia Shorter than normal men, male male testis hypospadias common 54. Consider the following diseases: 1. Huntington’s disease 2. Cystic fibrosis 3. Sickle cell anaemia 4. Haemophilia A Which of the following disorders are transmitted as autosomal recessive genetic disorders? A. 1, 2 and 4 B. 1 and 3 C. 2 and 3 D. 3 and 4 Ans. C (Harrison 15th ed., p 386) Sickle cell disease and cystic fibrosis are autosomal recessive genetic disorders. Huntington’s disease is autosomal dominant and hemophilia A is X-linked recessive. 2002.18 Rapid Digest UPSC – Combined Medical Services Examination Table: Mode of inheritence of various disease. Mode of inheritence Diseases Autosomal dominant Retinoblastoma, familial adenomatous polyposis, von-Hippel-Lindau syndrome, MEN I and II syndrome, hereditary spherocytosis, von-Willebrand's disease, HOCM, long QT syndrome, polycystic kidney disease, hereditary haemorrhagic telangiectasia, Peutz-Jegher syndrome, achondroplasia, Marfan syndrome, osteogenesis imperfecta, amyloidosis, Ehlers-Danlos syndrome, familial hypercholesterolaemia, Huntington's disease, neurofibromatosis type I and II, ALS, malignant hyperthermia, spinocerebeller ataxia type 1 and 2 Autosomal recessive Ataxia telangiectasia, sickle cell disease, β thalassemia, cystic fibrosis, α1 antitrypsin deficiency, Wilson's disease, haemochromatosis, congenital adrenal hyperplasia, glycogen storage disease type I-VIII, Gaucher disease, Tay-Sachs disease, phenylketonuria, Niemann Pick disease, Friedreich's ataxia X linked recessive Hemophilia A and B, G6PD deficiency, Menkes syndrome, androgen insensitivity, Becker and Duchenne muscular dystrophy, fragile X syndrome, adrenoleukodystrophy, spinobulbar muscular atrophy Y linked Male-to-female sex reversal. 55. A previously healthy factory worker was found unresponsive in his work place. He was afebrile, anicteric, tachypnoeic, drowsy and “blue” all over with clear lung fields and hyperdynamic cardiovascular findings. His ABG with 100% oxygen after intubation was: pH = 7.30 pO2 = 580 mmHg pCO2 = 30 mmHg SaO2 = 50% What is the most likely diagnosis? A. Methemoglobinemia B. Adult respiratory distress syndrome C. Carbon monoxide poisoning D. Organophosphorus poisoning Ans. A (Harrison 15th ed., p 671, 2606, 26012; 16th ed., p 211, 597-598) Tachypnoea, cyanosis with clear lung fields despite having PO 2 580 mm of Hg suggest diagnosis of methaemoglobinaemia. Presence of methemoglobin should be suspected in patients with hypoxic symptoms who appear cyanotic but have a PaO2 sufficiently high to fully saturate haemoglobin with oxygen. History of nitrate or other oxidant ingestion may not always be available. Cyanosis that is unresponsive to oxygen that usually occurs when the methaemoglobin level exceeds 15% (about 15 mg/L or 1.5 mg/dl). While in carbon monoxide poisoning arterial blood gas analysis may reveal metabolic acidosis, a normal PO2, decreased oxygen saturation and a variable PCO2. PO2 580 mm of Hg with hyperdynamic cardiovascular findings rules out carbon monoxide poisoning. As half-life of carboxyhemoglobin decreases after hyperbaric oxygen therapy and with PO2 580 mm of Hg symptoms of CO poisoning should not persist. 56. A patient is admitted with acute organophosphorous insecticide poisoning, develops ptosis, inability to lift the head and difficulty in breathing on the third day. The most likely diagnosis is: A. Hypokalemia B. Inflammatory polyneuropathy C. Intermediate syndrome D. Polymyositis Ans. C (Harrison 15th ed., p 2504, API Textbook of Medicine 5th ed., p 1399) In organophosphorous poisoning, on third day ptosis, inability to lift the head and difficulty in breathing are typical presentation of type II paralysis (intermediate syndrome). Intermediate syndrome (type II paralysis) is described from India and Sri Lanka in patients of organophosphorous poisoning. A group of symptoms like eye weakness, cranial nerve paralysis and weakness of neck and back muscles appear after a period of 1 to 2 days. These are followed by respiratory paralysis. UPSC Paper-1 2002 2002.19 57. Hybridoma technique is used to obtain: A. Purified antibodies B. Purified antigens C. Purified lymphocytes D. Purified macrophages Ans. A (Ananthanarayanan and Paniker 6th ed., p 128) Hybridoma technology is for production of unlimited quantities of identical monoclonal antibodies of same Ig class, possessing uniform specificity, affinity and other properties. Noble prize was awarded for hybridoma technology in 1984. 58. Which of the following disease is associated with the HLA B27 subtype? A. Addison’s disease B. Myasthenia gravis C. Reiter’s syndrome D. Psoriasis Ans. C (Harrison 16th ed., p 1993) Ankylosing spondylitis, Reiter’s syndrome, acute anterior uveitis, reactive arthritis and psoriatic spondylitis are associated with HLA B27. Adrenal insufficiency is associated with DR3 and psoriasis vulgaris is associated with Cw6. 59. Which of the following statements about antibodies is not correct: A. Human γ-globulins consist of at least 25 to 30 different proteins B. A typical immunoglobulin consists of 4 subunits C. γ-globulins are formed predominantly by the liver D. Immunoglobulins have a molecular weight of approximately 1,500,000 Ans. C (Harrison 16th ed., p 1921) γ-globulin is produced by plasma cells, which are differentiated B cells, and mediates the humoral arm of immune response. The main functions of the antibodies are to bind to an antigen for inactivation by body defence mechanism. Immunoglobulins are glycoproteins, each molecule containing two pairs of polypeptide chains held together by disulphide bonds. The smaller chains are called light or ‘C’ chains and larger ones heavy or ‘H’ chains. L chain Antigen binding site s Hinge region s Amino terminus s H chain Carboxy terminus Variable Constant region region Fig.: Immunoglobulin structure. 60. A 35-year old pilot has been detected to have pulmonary tuberculosis. Which one of the following should not be prescribed for him? A. Isoniazid B. Ethambutol C. Pyrazinamide D. Streptomycin Ans. B (Harrison 16th ed., p 949) 2002.20 Rapid Digest UPSC – Combined Medical Services Examination Ethambutol should be avoided in a pilot because it causes optic neuritis. There is reduced visual acquity, central scotoma and the loss of ability to see green colour. See also Q. 14 UPSC paper 1 2001 for adverse effects of antituberculous drugs. 61. Which of the following antibiotics if administered to a premature infant can cause grey baby syndrome? A. Tetracycline B. Chloramphenicol C. Clindamycin D. Netilmycin Ans. B (Harrison 16th ed., p 802) Chloramphenicol can cause a dose related grey baby syndrome in premature infants and neonates. There is cyanosis, fall in BP and death due to inability of the newborn to metabolize the drug. 62. A 50-year old patient wakes up with excruciating pain at the base of great toe with redness and swelling. Which would be the most desirable drug? A. Allopurinol B. Probenecid C. Sulphinyrazone D. Indomethacin Ans. D (Harrison 16th ed., p 2045) The clinical feature is typical of acute attack of gout. For acute attack the effective drugs are indomethacin 25 to 50 mg tid, ibuprofen 800 mg tid or diclofenac 50 mg tid. Allopurinol, probenecid and sulphinpyrazone are uricosuric drugs and are used to reduce serum uric acid level. These drugs should be avoided during acute attack as they may further aggravate the condition. 63. Match List-I (Clinical disorders) with List-II (Mechanism) and select the correct answer using the codes given below the Lists: List-I (Clinical disorders) List-II (Mechanism) a. Distal renal tubular acidosis 1. Addition of excessive acid to plasma b. Proximal renal tubular acidosis 2. Inadequate renal NH4 production c. Diabetic ketoacidosis 3. Inability to maintain H+ gradient between blood and urine d. Chronic renal failure 4. Loss of HCO3 in urine Codes: A. a b c d B. a b c d C. a b c d D. a b c d 4 3 2 1 3 4 1 2 4 3 1 2 3 4 2 1 Ans. B (Harrison 16th ed., p 1698-1699) Distal RTA is type 1 RTA. In this disease the distal nephron is not able to lower urine pH normally either because the collecting ducts permit excessive back diffusion of H+ from lumen to blood or because of inadequate transport of H+. Proximal RTA is type 2 RTA. There is generalized disorder of function of proximal tubule. Bicarbonate reabsorption in proximal tubule is defective resulting in bicarbonateuria. In diabetic ketoacidosis ketone bodies are in high quantity in blood and they decrease the pH of blood. In CRF the production of ammonia is decreased. Metabolic acidosis is very common in later stages of CRF. 64. Hemoptysis may occur in all of the following conditions except: A. Pulmonary embolism B. Pulmonary tuberculosis C. Pulmonary stenosis D. Mitral stenosis Ans. C (Harrison 16th ed., p 208) In pulmonary stenosis (mainly congenital, rheumatic) there are features of right-sided heart failure. Haemoptysis is absent. In pulmonary embolism there is pulmonary infarction and haemoptysis. In pulmonary tuberculosis haemoptysis is a common feature. Chronic cough, low-grade evening rise of temperature with haemoptysis indicate tuberculosis. In mitral stenosis haemoptysis is due to elevated pulmonary venous pressure and rupture of pulmonary-bronchial venous connections. UPSC Paper-1 2002 2002.21 65. Match List-I (Retinal changes) with List-II (Clinical conditions) and select the correct answer using the codes given below the Lists: List-I (Retinal changes) List-II (Clinical conditions) a. Subhyaloid haemorrhage 1. Hypertensive retinopathy b. Capillary microaneurysm 2. Diabetic retinopathy c. Cherry red spot 3. Central retinal artery occlusion d. Flame shaped haemorrhage 4. Subarachnoid haemorrhage Codes: A. a b c d B. a b c d C. a b c d D. a b c d 4 2 3 1 1 2 3 4 4 3 2 1 1 3 2 4 Ans. A Central retinal artery occlusion is nearly always at the lamina cribrosa where the vessels normally become slightly narrowed. The eye becomes suddenly blind. Examination of fundus reveals loss of transparency in retina. At the fovea centralis where the retina is extermely thin the red reflex from the choroid is visible and appears as ‘cherry red’ spot. Diabetic retinopathy is of two types, simple (background) and proliferative. Background retinopathy, lesions are increased capillary permeability, capillary closure and dilatation, microaneurysms, AV shunts, dilatation of vein, dot and blot haemorrhages, cotton wool spots and hard exudates. Proliferative retinopathy, lesions are new vessels, retinitis, proliferans, vitreal haemorrhage, retinal detachment. Subhyaloid haemorrhage is seen is subarachnoid haemorrhage. Hypertensive retinopathy is classified into 4 grades. Flame shaped haemorrhage is seen in grade III or grade IV retinopathy. 66. Which one of the following features is common to all forms of shock? A. Decrease in tissue perfusion B. Decrease in left atrial pressure C. Decrease in cardiac output D. Decrease in right atrial pressure Ans. A (Harrison 15th ed., p 222; 16th ed., p 1581) In Harrison shock is defined as the clinical syndrome that results from inadequate tissue perfusion. Irrespective of the cause there is decreased O2 and substrate supply at the tissue level. The cellular injury leads to release of inflammatory mediators that lead to structural and functional damage. Remember the following important points commonly asked in examination: 1. The classic signs of shock appear when there is ≥ ~ 40% loss of blood volume. 2. In hyperdynamic septic shock cardiac output is normal or increased. 3. Cardiogenic shock occurs when 40% or more of left ventricle is damaged by myocardial infarction. 67. The vitamin used in the treatment of convulsion in alcoholism is: A. Thiamine B. Riboflavin C. Niacin D. Vitamin B12 Ans. A (Harrison 15th ed., p 2565; 16th ed., p 2563) Alcoholics are almost always deficient in thiamine. Thiamine replacement in high dose 50-100 mg daily is required. However during convulsion it should be controlled with IV diazepam. 68. Wound healing is the summation of following processes except: A. Coagulation B. Matrix synthesis C. Angiogenesis D. Fibrolysis Ans. D (Bailey and Love 24th ed., p 84) Wound healing is summation of a number of processes which follow injury including: Coagulation → Inflammation → Matrix synthesis and deposition → Angiogenesis → Fibroplasia → Epithelialization → Contraction → Remodelling and scar maturation. In human regeneration is limited to epithelium and the liver. Healing by first intention occurs in wounds with apposed edges. Healing of clean, uninfected surgical incision approximated by surgical sutures is an example of primary union or healing by first intention. 2002.22 Rapid Digest UPSC – Combined Medical Services Examination 69. Complete restoration of tensile strength of the wound comparable to normal tissue takes as long as: A. Two weeks B. Six weeks C. Six months D. Two years Ans. C (Robbins 6th ed., p 109) At the end of 1st week wound strength is about 10% of unwounded skin but it increases rapidly over next 4 weeks. This rate of increase then slows at approximately the third month after the original incision and then reaches a plateau at about 70 to 80% of the tensile strength of unwounded skin, which may persist for life. The recovery of tensile strength results from increased collagen synthesis exceeding collagen degradation during the first 2 months and from structural modifications of collagen fibers (cross linking, increased size), when collagen synthesis ceases at later times. This statement indicates that after 3 months maximum tensile strength is reached and hence the answer is choice C. 70. Consider the following statements regarding HIV: 1. The risk of infection is 10 times more with solid needle than hollow needle 2. The mode of transmission is mainly through infected blood 3. CD4 cell count is directly related to viral load 4. Post exposure prophylaxis should start within one hour of contamination Which of these statements are correct? A. 1 and 2 B. 2 only C. 3 and 4 D. 2, 3 and 4 Ans. C (Harrison 16th ed., p 1088, 1137) The level of CD 4+ T cells decreases gradually and progressively in HIV infected persons. CD4+ T cell count reflects the immune status of HIV infected person. The risk of acquiring HIV from needle stick injury is 0.3% and it is more with hollow needle containing blood or body fluids than solid needles. The main mode of HIV transmission is sexual. With screening of blood or blood products for HIV, the transmission of HIV through contaminated blood has decreased considerably. Post exposure prophylaxis should be started as early as possible. Combination of two nucleoside analogue reverse transcriptase inhibitors is given for 4 weeks for routine exposure and in rest of the high-risk cases a protease inhibitor is also given for 4 weeks. 71. Multiple pigmented and puckered sinuses with lymph node enlargement in the neck are diagnostic of: A. Actinomycosis B. Osteomyelitis of mandible C. Pyoderma D. Tubercular lymphadenitis Ans. A (Harrison 16th ed., p 937) The patient is most likely suffering from actinomycosis. It commonly involves the oral, cervical or facial site usually a soft tissue swelling, abscess or mass lesion often mistaken for malignancy. The angle of the jaw is commonly involved. It is mainly caused by Actinomyces israelii. When it invades the subcutaneous tissue there is induration and pus formation. Gradually multiple sinus tracts are formed. Sulphur granules are demonstrated in pus. Intravenous penicillin for 2 to 6 weeks followed by oral amoxycillin for 6 to 12 weeks is a reasonable treatment option. 72. Which one of the following cancers is caused by a virus? A. Kaposi’s sarcoma B. Malignant melanoma C. Retinoblastoma D. Mesothelioma Ans. A (Harrison 16th ed., p 1120) Kaposi’s sarcoma is associated with AIDS caused by HIV virus. It is due to excessive proliferation of spindle cells, which are probably of vascular origin and have features common with endothelial and smooth muscle cells. The development of Kaposi’s sarcoma is dependent on several factors like HIV-1 itself, HHV-8 (Kaposi’s sarcoma associated herpes virus), immune activation and cytokine secretion. UPSC Paper-1 2002 2002.23 73. In chronic pyloric stenosis, which of the following electrolyte and pH changes occur? A. Hypochloremic, hypokalaemic acidosis B. Hypochloremic, hypokalaemic alkalosis C. Hyperchloremic, hyperkalaemic acidosis D. Hyperchloremic, hyperkalaemic alkalosis Ans. B (Bailey and Love 24th ed., p 1033) Hypernatraemia does not occur in hypertrophic pyloric stenosis. Alkalosis cccurs in hypertrophic pyloric stenosis due to loss of acid from stomach. Along with it there is loss of K+ and Cl– ion. Severe vomiting also leads to loss of Na+ ions. A child suffering from hypertrophic pyloric stenosis needs to be rehydrated with dextrose-saline and potassium (2.5% dextrose plus 0.45% NaCl plus 1 g of KCl per 500 ml of fluid). After this Ramstedt’s operation should be done. 74. A person suffering from varicose veins of the right lower limb is found to be bleeding profusely from the leg while working. The immediate action required is: A. Shift him immediately to the hospital B. Apply a tourniquet to the thigh C. Lower the limb and apply pressure bandage D. Elevate the limb and apply pressure bandage Ans. D (Bailey and Love 24th ed., p 957) Elevate the limb and apply pressure bandage is the main immediate treatment. When large superficial varices are damaged spectacular hemorrhage can occur. Laying the patient down, elevating the legs and applying compression bandage easily controls this. Most serious problem of varicose vein is venous ulceration. Other complications include thrombosis, which refers to superficial thrombophlebitis although deep vein thrombosis may also occur. Varices are recognized as tortuous dilated veins in the leg but physiologically speaking a varicose vein is one, which permits reverse flows through its faulty valves. Varicose vein incidence is more in: 1. Females. 2. During pregnancy. 3. People who stand during their work. A major factor is inheritance. 75. Consider the following investigations: 1. Thyroid scintigraphy 2. Ultrasonography 3. Thyroid hormone assay 4. Fine needle aspiration cytology In the case of a patient who has hard solitary thyroid nodule in right lobe, which of these investigations are recommended? A. 1 and 2 B. 2 and 3 C. 1 and 4 D. 2, 3 and 4 Ans. C (Schwartz Principles of Surgery 6th ed., p 1632) Algorithm for diagnosis of thyroid nodule Thyroid nodule Thyroid scintigraphy Operation Hyperthyroid Cold Hot Radioactive iodine Ultrasonography Euthyroid Observe Cystic Solid Aspiration and Operation, suppression T4 suppression or needle biopsy 2002.24 Rapid Digest UPSC – Combined Medical Services Examination It is clear that when differentiation between cystic and solid is clear there is no need of ultrasonography. Many authorities emphasize an importance of early use of fine needle aspiration with cytological examination although it is unable to differentiate between follicular adenoma and follicular carcinoma. 76. Consider the following statements: 1. Pharyngeal diverticulum is a protrusion of a pouch through the neck defect called, Killian’s dehiscence 2. It is initiated by imperfect relaxation of the strap muscles 3. It is common in males and usually presents as a left sided neck swelling 4. Cricopharyngeal myotomy is an essential component of its surgical procedure Which of these statements are correct for pharyngeal diverticulum? A. 1, 2 and 4 B. 1, 3 and 4 C. 1, 2 and 3 D. 3 and 4 Ans. A (Bailey and Love 24th ed., p 753) Pharyngeal pouch is a protrusion of mucosa through Killian’s dehiscence, weak area of pharyngeal wall between oblique fibres of thyropharyngeus and transverse fibres of cricopharyngeus at lower end of inferior constrictor. Pharyngeal diverticulum is twice as common in women as in men and is more common after 60 years. Barium swallow either alone or videofluorosocpic study are investigations done for diagnoses. In all cases a myotomy dividing the fibres of the cricopharyngeus muscle and the upper oesophageal circular muscle fibres must be performed. Presenting symptoms are dysphagia, associated with the spontaneous regurgitation of undigested, bland material, often interrupting eating or drinking. Symptoms of dysphagia are initially due to loss of muscle compliance in pharyngoesophageal segment, later augmented by the presence of an enlarging diverticulum. 77. In a mammogram, all of the following are features of carcinoma breast except: A. A solid lesion with ill defined edge or stellate configuration B. True macrocalcification C. Areas of macrocalcification D. Increased skin thickness Ans. C (Schwartz Principles of Surgery 6th ed., p 540; Harrison 16th ed., p 518) Macrocalcification is not of significance in diagnosis of breast cancer. Microcalcification, as a sign of malignancy, assumes greater importance in younger women in whom it may be the sole mammographic feature. Subtle abnormalities that are seen in mammography should be evaluated by compression or magnified view. Various such abnormalities on mammogram are: 1. Clustered microcalcification. 2. Densities especially spiculated or with irregular margins. 3. New or architectural distortion. 4. Secondary signs of malignancy such as: – Duct dilatation. – Architectural distortions. – Asymmetry. – Fibronodular densities. Importance of calcification as a sign of malignancy diminishes with age. Mammography is not a substitute for biopsy rather this technique is an adjuvant, complementary study that augments history and physical examination. Dose of radiation per study is 0.1 rad per study as compared to 5 rad on plain X ray examination. In xeromammography, image is recorded on xerographic plate rather than a conventional transparency. Magnification mammography: Magnification of 1 to 5 times enhances the sharpness of detail and increases diagnostic accuracy. UPSC Paper-1 2002 2002.25 78. Match List-I with List-II and select the correct answer using the codes given below the Lists: List-I List-II a. Charcot’s triad 1. Acute cholecystitis b. Courvoisier’s law 2. Acute cholangitis c. Caroli’s disease 3. Carcinoma head of pancreas d. Murphy’s sign 4. Saccular dilatation of the intrahepatic ducts Codes: A. a b c d B. a b c d C. a b c d D. a b c d 2 3 4 1 1 4 3 2 2 4 3 1 1 3 4 2 Ans. A (Harrison 15th ed., p 1782, 1784) In CA head of the pancreas the gall bladder is palpable. In case of CBD stone distended gall bladder is not seen as the organ is usually already shrivelled from previous repeated attacks of inflammation (Courvoisier’s law). Pain, jaundice and fever with rigor is known as Charcot’s triad. It is a feature of acute cholangitis seen in CBD stones. In Caroli’s disease there is cystic dilatation of the intrahepatic bile ducts and involves the major intrahepatic radicles. There is recurrent cholangitis, abscess formation in and around the ducts and sometimes gallstones are formed in the ectatic intrahepatic radicles. Murphy’s sign is seen in acute cholecystitis. During palpation of gall bladder there is inspiratory arrest. 79. A case of portal hypertension has serum bilirubin 2.5 mg/dl, albumin 3.5 gm/dl and minimal ascites. The patient never had haematemesis. Which one of the following statements is correct? A. Patient is grouped as Child’s grade A and treated by selective shunt B. Patient is grouped as Child’s grade B and treated conservatively C. Patient is grouped as Child’s grade B and treated by selective shunt D. Patient is grouped as Child’s grade A and treated conservatively Ans. B (Harrison 16th ed., p 1813; Bailey and Love 24th ed., p 1065) The patient is suffering from Child’s grade B. See answer of question 15 for details of Child’s grading. Since the patient is not suffering from haematemesis shunting is not required and may be treated conservatively. 80. Consider the following features with reference to Zollinger-Ellison syndrome: 1. Intractable peptic ulceration 2. Hypergastrinaemia 3. β-islet-cell tumour of the pancreas Which of these features are present in Zollinger-Ellison syndrome? A. 1 and 3 B. 2 and 3 C. 1, 2 and 3 D. 1 and 2 Ans. D (Harrison 16th ed., p 1758) Zollinger Ellison syndrome is characterised by high gastric acid output due to hypergastrinemia from a non beta cell tumour of pancreas (gastrinoma). Gastrinomas are either sporadic or belong to MEN type I syndrome. Peptic ulcer is the commonest clinical manifestation. Diarrhoea is the second commonest clinical feature. The most sensitive and specific gastrin provocative test is secretin study. Calcium infusion test is less sensitive. Proton pump inhibitors are the treatment of choice. Octreotide is also used. The main goal of surgery is cure but surgical cure rate is about 30%. 81. The following can be associated with acute pancreatitis except: A. Hyperparathyroidism B. Hyperthyroidism C. Hypercalcemia D. Hypertriglyceridemia Ans. B (Harrison 16th ed., p 1896) Hyperthyroidism is not related with pancreatitis. The various important factors for pancreatitis are alcoholism, gallstones, postoperative state, ERCP, posttraumatic, hypertriglyceridaemia, hypercalcaemia (hyperparathyroidism), mumps, viral hepatitis, renal failure, vasculitis, drug induced (azathioprine, 6-MP, sulfonamides, thiazide, frusemide, oestrogen) etc. 2002.26 Rapid Digest UPSC – Combined Medical Services Examination 82. A patient following open inguinal hernia repair can have neuralgia due to involvement of any of the following nerves except: A. Ilioinguinal B. Iliohypogastric nerve C. Lateral cutaneous nerve of thigh D. Genitofemoral nerve Ans. C (Schwartz Principles of Surgery 6th ed., p 1536) Residual neuralgia, after surgical handling of the sensory nerves in groin during hernioplasty or after hernioplasty from constricting scar or adjacent inflammatory granules, may be identified by local nerve block. Nerves involved in neuralgias identified are: Iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve. Lateral cutaneous nerve of the thigh is not involved in neuralgia. Iliohypogastric and ilioinguinal neuralgia are identified by block and division in groin. While genitofemoral neuralgia is identified by blocking L1 and L2 paravertebrally. Management of neuralgia is difficult. Early neurolysis and division of nerve are used. Various adjuvants of use are analgesics, antidepressants, anticonvulsants and anxiolytic drugs. Transcutaneous electrical simulation and injection of steroids are also used. 83. The ideal treatment for congenital inguinal hernia is: A. Herniotomy B. Herniorrhaphy C. Hernioplasty D. Preperitoneal repair Ans. A (Bailey and Love 24th ed., p 1176) Inguinal herniotomy is basic operation which entails dissecting out and opening the hernial sac, reducing any content and then transfixing the neck of sac and removing the remainder. It is employed as such or as a first step in a repair procedure (herniorrhaphy). By itself, it is sufficient for the treatment of hernia in infants, adolescents and young adults. In infants, it is not necessary to open the canal as the internal and external rings are superimposed. 84. Which one of the following is not considered as precancerous lesion for carcinoma of the large bowel? A. Familial intestinal polyposis B. Villous adenoma C. Chronic ulcerative colitis D. Peutz-Jegher’s polyposis Ans. D (Harrison 16th ed., p 198; Bailey and Love 24th ed., p 1176) Peutz-Jeghers syndrome is characterized by presence of hamartomatous polyps in intestine. There is associated mucocutaneous pigmentation with tumours of ovary, breast, pancreas, endometrium etc. The malignant potential is rare. Villous adenoma is a risk factor for CA colon. The risk of developing malignancy in a villous adenoma more than 2 cm in diameter is 15%. They turn into malignant tumour 3 times more commonly than tubular adenoma. In villous adenoma there is risk of hypokalaemia with mucous diarrhoea. Colorectal cancer is very strongly associated with familial polyposis coli. It is a rare condition where the colon is filled up of numerous adenomatous polyps. It is transmitted as autosomal dominant disease. It is associated with deletion of long arm of chromosome 5. CA colon is also seen in patients suffering from chronic ulcerative colitis. Remember the following syndromes: Gardner’s syndrome: Colonic polyps with soft tissue and bony tumours, congenital hypertrophy of retinal pigment epithelium, mesenteric desmoid tumours and ampullary cancer. Turcot’s syndrome: Polyposis coli with malignant CNS tumours. Lynch syndrome: Large intestine polyp with endometrial and ovarian tumour. High malignant potential. 85. The treatment of choice for cancer of the anal canal is: A. Radiation B. Abdomino-perineal resection C. Chemo-radiation D. Surgery and radiation Ans. C (Bailey and Love 24th ed., p 1271) Combination of chemotherapy (5-FU + mitomycin) and radiotherapy (chemoradiation) has now become preferred initial therapy for all anal canal tumors. This therapy for tumours with diameter > 5 cm has high failure rate. Abdomino-perineal resection is reserved for patient with faecal incontinence and those who develop recurrence after conservative treatment. UPSC Paper-1 2002 2002.27 86. Match List-I (Disease) with List-II (Radiological signs) and select the correct answer using the codes given below the Lists: List-I (Diseases) List-II (Radiological signs) a. Acute intestinal obstruction 1. Multiple fluid levels b. Duodenal perforation 2. String sign of Kantor c. Acute pancreatitis 3. Gas under diaphragm d. Crohn’s disease 4. Sentinel loop sign Codes: A. a b c d B. a b c d C. a b c d D. a b c d 3 1 4 2 1 3 4 2 1 3 2 4 3 1 2 4 Ans. B In acute intestinal obstruction multiple fluid levels are seen in X-ray abdomen erect posture AP view. In duodenal perforation there is collection of gas/air in peritoneal cavity. This is visualized under the diaphragm in X-ray abdomen erect posture AP view. In Crohn’s disease there is circumferential inflammation and fibrosis that results in long segments of luminal narrowing. This is seen radiologically as string sign of Kantor. Sentinel loop sign is a dilated bowel loop seen in X-ray in acute pancreatitis. 87. The closest differential diagnosis of rectal prolapse is: A. Prolapsed haemorrhoids B. Intussusception C. Anorectal carcinoma D. Mucosal oedema of ulcerative proctocolitis Ans. B (Bailey and Love 24th ed., p 1225) In case of child with abdominal pain prolapse of rectum must be distinguished from ileocaecal intussusception protruding from anus. In rectosigmoid intussusception in the adult, there is a deep groove (5 cm or more) between the emerging protruding mass and margin of the anus, into which the finger can be entered. 88. Consider the following statements: Retesting by urea breath test in Heliobactor pylori is indicated: 1. In patients with gastric MALT lymphoma 2. When a peptic ulcer is complicated by haemorrhage 3. After resection of early gastric cancer 4. When there is a family history of gastric cancer Which of these are correct statements? A. 1, 2, 3 and 4 B. 1, 2 and 3 C. 2, 3 and 4 D. 1 and 4 Ans. A (Yamada T, Textbook of Gastroenterology 4th ed., p 1426, 2754, Harrison 15th ed., p 912) Gastric MALT lymphoma is strongly associated with H. pylori. Treatment of H. pylori is very important in gastric lymphoma. There are several studies which suggest that detection and treatment of H. pylori reduces the incidence of peptic ulcer bleeding. Gastric adenocarcinoma is associated with H. pylori gastritis and intestinal metaplasia and hence detection and treatment of H. pylori is required. Harrison mentions the importance of detection and eradication of H. pylori where there is a family history of gastric cancer. 89. Revised trauma score by Champion include the following except: A. Glasgow coma scale B. Systolic blood pressure C. Respiratory rate D. Pulse rate Ans. D (Bailey and Love 22nd ed., p 20) Revised trauma score devised by Champion is widely accepted and applied. 2002.28 Rapid Digest UPSC – Combined Medical Services Examination Data derived from vital signs and level of consciousness is mathematically combined into a single variable that correlates with mortality. This revised trauma score incorporates the Glasgow coma scale which measures the level of consciousness with trauma scores relating to the cardiovascular and respiratory systems. High scoring equates with good prognosis. See also Q. 34 UPSC paper 1 2001 for revised trauma scale. 90. Match List-I (Clinical conditions) with List-II (Nerve involved) and select the correct answer using the codes given below the Lists: List-I (Clinical conditions) List-II (Nerve involved) a. Wrist drop 1. Ulnar nerve b. Winging of scapula 2. Radial nerve c. Pointing index 3. Long thoracic nerve d. Claw hand 4. Median nerve Codes: A. a b c d B. a b c d C. a b c d D. a b c d 2 3 4 1 1 4 3 2 2 4 3 1 1 3 4 2 Ans. A The answer is self explanatory. 91. Repair of cleft lip is usually carried out: A. At birth B. At 10 weeks of life C. During 1½ to 2 years age D. Before the child starts going to school Ans. B (Bailey and Love 23rd ed., p 590; 24th ed., p 649) Cleft lip is normally repaired at about 10 weeks after birth. Cleft palate is usually repaired between 14 and 15 months but may be deferred even until 2-3 years of age. Table: Time of operation of cleft lip and cleft palate. 1. Cleft lip alone: Unilateral One operation at 5-6 months Bilateral One operation at 4-5 months 2. Cleft palate alone: Soft palate only One operation at 6 months Soft and hard palate Soft palate at 6 months and hard palate at 15-18 months 3. Cleft lip and palate: Unilateral Cleft lip and soft palate at 5-6 months; hard palate and gum pad with or without lip revision at 15-18 months Bilateral Cleft lip and soft palate at 4-5 months; hard palate and gum pad with or without lip revision at 15-18 months 92. The treatment of choice in grade-4 subcapital fracture neck of femur in a fifty year old patient is: A. Pin-in-situ B. Reduction C. Hemiarthroplasty D. Total hip replacement Ans. C (Bailey and Love 23rd ed., p 375) Garden classified fracture neck of femur into 4 grades: Grade 1 is an incomplete fracture of the neck. Grade 2 is a complete fracture of neck without displacement. Grade 3 has moderate displacement of less than half the diameter of the femoral neck. Grade 4 is a complete off-ended femoral head as seen in the AP or lateral X ray. UPSC Paper-1 2002 2002.29 Table: Treatment of various grades of fracture neck of femur. Age < 50 50-70 70-80 > 80 Grade I Pin in situ Pin in situ Pin in situ Hemiarthroplasty /pin in situ Grade II Pin in situ Pin in situ Pin in situ or hemiarthroplasty Hemiarthroplasty Grade III Reduce and pin Reduce and pin Hemiarthroplasty Hemiarthroplasty Grade IV Total hip replacement Hemiarthroplasty Hemiarthroplasty Hemiarthroplasty or reduce with pin 93. Which one of the following is not a radiological feature of osteoarthritis? A. Widening of the joint space B. Osteophyte formation C. Subchondral sclerosis D. Cyst formation Ans. A (Maheshwari 3rd ed., p 253) Joint space is decreased in osteoarthritis. Diagnosis of osteoarthritis is mainly radiological. Following are some of radiological features: 1. Narrowing of joint space. 2. Subchondral sclerosis (dense bone under the articular surface). 3. Subchondral cysts. 4. Osteophyte formation. 5. Loose bodies. 6. Deformity of joint. Osteoarthritis is a degenerative joint disease. Primary OA occurs in old age, mainly in weight bearing joints (hips and knee). In generalised variety, the trapezio-metacarpal joint of thumb and distal interphalangeal joints of fingers are also affected. Primary OA is more common than secondary OA. 94. A dinner-fork deformity is classically seen in: A. Monteggia fracture B. Fracture of the scaphoid C. Colles’ fracture D. Smith’s fracture Ans. C (Maheshwari 3rd ed., p 29) Dinner fork deformity is seen in Colles’ fracture. Colles’ fracture occurs at the distal end of the radius, at its corticocancellous junction (about 2 cm from distal articular surface), in adults with typical displacement. Displacements seen in Colles’ fracture are: 1. Impaction of fragments. 2. Dorsal displacement. 3. Dorsal tilt. 4. Lateral displacement. 5. Lateral tilt. 6. Supination. Dorsal tilt is the most characteristic displacement. Most displacements can be identified on X ray except for supination. Treatment of Colles’ fracture is essentially conservative. For an undisplaced fracture immobilization in a below elbow plaster cast for 6 weeks is sufficient. Plaster cast is applied extending from below the elbow to the metacarpal heads, maintaining the wrist in palmar flexion and ulnar deviation. Hand is grasped as if he is shaking hand while reducing the fracture. Complications of Colles’ fracture: 1. Stiffness of joints: Finger stiffness is commonest complication. Shoulder, elbow, and wrist joint may also become stiff. 2. Malunion: Colles’ fracture always unites but malunion occurs in a large proportion of cases. 3. Subluxation of inferior radioulnar joint. 2002.30 Rapid Digest UPSC – Combined Medical Services Examination 4. Carpel tunnel syndrome. 5. Sudeck‘s osteodystrophy. 6. Rupture of the extensor pollicis longus tendon. 7. Delayed union and non union are rare. Table: Injuries with characteristic deformities. Flattening of Shoulder: Shoulder dislocation (anterior). Dinner fork deformity: Colles’ fracture. Mallet finger: Avulsion of insertion of extensor tendon from distal phalanx of the finger. Flexion, adduction and internal rotation of the hip: Posterior dislocation of hip. Abduction, external rotation of hip: Anterior dislocation of hip. External rotation of leg: Fracture neck of femur, intertrochanteric fracture. Gun stock deformity: Malunited spracondlyar fracture of humerus. Garden spade deformity: Smith fracture. 95. Empyema necessitatis is defined as when: A. Pleural empyema is under pressure B. Pleural empyema has ruptured into the bronchus C. Pleural empyema has ruptured into the pericardium D. Pleural empyema is showing extension to the subcutaneous tissue Ans. D (Bailey and Love 23rd ed., p 796) Empyema is grossly purulent pleural effusion. Sometimes it protrudes through the thoracic cage and forms a fluctuant mass under the skin. This is called empyema necessitatis. In early stage of empyema a brief period of drainage along with antibiotics is often sufficient. But these measures may fail in a chronic empyema. Chest drains should be inserted by a small thoracotomy and if required a portion of rib may be removed. Drainage is required for a longer period and high dose of appropriate antibiotics are given. If these fail to expand the lungs then decortication is required. 96. The following are true about bronchogenic carcinoma except: A. It is the commonest malignant tumour in men B. One-Lung-Anaesthesia has improved results of surgery C. Most lung cancers are unresectable at presentation D. Small cell carcinoma carries better survival rate Ans. A and D (Harrison 15th ed., p 491, 608; 16th ed., p 435, 514) Prostate CA is the commonest cancer diagnosis and the second leading cause of cancer death in men. Autopsy of men in the eighth decade of life shows CA prostate in >70% cases. CA lung is the leading cause of cancer deaths in men and women in all races. The prognosis of small cell CA of lungs is very poor. It is very aggressive tumour and usually spreads widely at the time of diagnosis. The median survival is only 6 to 17 weeks without treatment. Even with combination chemotherapy the median survival may be only between 40 to 70 weeks. 97. Consider the following statements: Polycystic disease of the kidneys may present with: 1. Chronic renal failure 2. Hematuria and renal colic 3. Hypertension 4. Accidentally on routine examination of abdomen Which of these statements are correct? A. 1 and 3 B. 2 and 4 C. 1, 3 and 4 D. 1, 2, 3 and 4 Ans. D (Harrison 16th ed., p 1695) Adult polycystic kidney disease is an autosomal dominant disorder. It is the most common inherited nephropathy. 8% of patients have intracranial aneurysm. 30% of patients have hepatic cysts. MVPS is present in 20% of ADPKD patients whereas it is present in only 2-3% of general population. UPSC Paper-1 2002 2002.31 All the given choices are clinical features of polycystic kidney disease. Besides this UTI is common. Nephrolithiasis occurs in 15-20% patients. Progressive renal failure is common and by age 60, 50% of patients develop end stage renal disease. 98. Which one of the following is the serious complication of degenerative myopia in the eye? A. Retinal detachment B. Vitreous liquefaction C. Myopic crescent D. Posterior staphyloma Ans. A (Parsons’ Diseases of the Eye 19th ed., p 81) Pathological myopia is essentially degenerative and progressive condition that manifests in early childhood. Complications of pathological myopia are: Posterior staphyloma. Vitreous degeneration. Myopic crescent: Annular ring. Retinal haemorrhage and lattice degeneration leading to detachment of retina and complicated cataract. Among above complications retinal detachment is most serious impairing vision. 99. Which one of the following conditions does not cause pseudoexophthalmos? A. High myopia B. Lid retraction C. Optic nerve glioma D. Facial nerve paralysis Ans. C (Parsons’ Diseases of the Eye 19th ed., p 507) Optic nerve glioma is a space occupying lesion of the orbit. It causes true exophthalmos by pushing the eyeball outwards. In rest of the three conditions the eyeball remains in its original position. 100. Hoarseness secondary to bronchogenic carcinoma is usually due to extension of the tumour into: A. Vocal cord B. Superior laryngeal nerve C. Left recurrent laryngeal nerve D. Right vagus nerve Ans. C (Harrison 16th ed., p 508) Bronchogenic CA spreads to involve left recurrent laryngeal nerve. It leads to vocal cord dysfunction and hoarseness of voice. 101. Multiple perforations of tympanic membrane is a feature of: A. Trauma B. Tuberculous otitis media C. CSOM D. Aspergillosis Ans. B (Dhingra 3rd ed., p 95, Logan Turner 10th ed., p 293) Multiple perforations 2 or 3 in number are seen in pars tensa and form a classical sign of tubercular otitis media. Tubercular otitis media In most cases infection is secondary to pulmonary tuberculosis. Infection reaches middle ear through eustachian tube. It is a slow insidious process. Tubercles form in submucosal layers of middle ear cleft. It may caseate. Necrosis of tympanic membrane is painless. Multiple perforations may form which coalesce to form single large perforation. Clinical features 1. Painless ear discharge: Earache is characteristically absent. Discharge is often foul smelling because of underlying bone destruction. 2. Perforation: Multiple perforations, 2 or 3 in number, are seen in pars tensa and form classical sign of disease. 3. Hearing loss: There is severe hearing loss, out of proportion to symptoms. There is mainly conductive hearing loss. 4. Facial paralysis: Common complication and may be presenting feature in a child. Diagnosis Culture of ear discharge, histopathological examination of granulation. 2002.32 Rapid Digest UPSC – Combined Medical Services Examination Treatment 1. Systemic ATT. 2. Local treatment in form of ear toilet and control of secondary infection. 3. Mastoid surgery is indicated for complications. 102. The following are the clinical features of raised intracranial tension except: A. Headache B. Insomnia C. Bradycardia D. Papilloedema Ans. B (Harrison 16th ed., p 1633) Insomnia is not a feature of raised ICT. Drowsiness with diminished level of consciousness is an important feature of raised ICT. Headache with vomiting is an important symptom of raised ICT. Bradycardia with systolic hypertension known as Cushing’s reflex is seen in raised ICT. Papilloedema is one of the main signs that is looked for in all patients with raised ICT. The normal ICP is 5-15 mmHg. The various treatment options to reduce ICP are: a. Mechanical ventilation and lower PCO2. b. Steroid: Inj. dexamethasone 4 mg IV 6 hourly. c. Mannitol: 1 g/kg 4-6 hourly. d. Barbiturate: Thiopentone 3-5 mg/kg. e. Frusemide. f. Hypothermia. 103. Which one of the following is not true regarding obstetric brachial plexus palsy? A. Upper roots are mostly affected B. Results from traction on shoulder girdle C. Good progress with immediate surgery D. Good prognosis with conservative management Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 486-487) Treatment in both obstetric Erb’s palsy and Klumpke’s palsy is conservative. In brachial palsy, either the nerve roots or the trunk of brachial plexus are involved. Damage is due to stretching (common) or effusion or haemorrhage inside sheath. Tearing of fibres is rare. Cause is undue traction on neck during attempted delivery of shoulder dystocia or even in normal delivery. Unilateral involvement is common. 2 clinical types are present. Rarely both types are present together. Erb’s palsy This is commonest type when 5th and 6th cervical nerve roots are involved. Resulting paralysis causes arm to lie on side with extension of elbow, pronation of forearm and flexion of wrist (porter/policeman tip hand). Moro reflex and biceps jerk are absent on affected side. Treatment Consist of use of splint so as to hold the arm abducted to right angle and externally rotated. Forearm is flexed at right angle and supinated and hand is dorsiflexed. Full recovery takes weeks or even months. Severe injury may produce permanent disability. Klumpke’s palsy Due to affection of lower cord involving 7th and 8th cervical or even 1st thoracic root. There is paralysis of muscles of forearm with wrist drop and flaccid digits. Arm is flexed at elbow. Wrist extended, hand flaccid and fingers flexed. When 1st thoracic nerve is involved, there may be homolateral ptosis with small pupil due to sympathetic nerve involvement. Treatment Consists of splinting of arm with forearm pronated and fingers extended. Prognosis is good if it is due to stretching. Aeroplane splint is used in brachial plexus injury. UPSC Paper-1 2002 2002.33 104. Ramstedt’s operation is the surgical procedure for: A. Congenital atresia of duodenum B. Hallux valgus C. Congenital hypertrophic pyloric stenosis D. Atresia of bile duct Ans. C (Bailey and Love 24th ed., p 1033) Ramstedt’s operation/seromyotomy is done for congenital hypertrophic pyloric stenosis. Duodenoduodenostomy/duodenojejunostomy is done for congenial atresia of duodenum. Heller’s operation is done for Achalasia cardia. 105. The commonest cause of bleeding per rectum in children is: A. Rectal polyp B. Intussusception C. Meckel’s diverticulum D. Haemorrhoids Ans. A (Schwartz Prnciples of Surgery 6th ed., p 1267) According to Schwartz the most common cause of gastrointestinal bleeding in a child is juvenile polyp. Approximately 1% of all infants will have a single juvenile polyp in infancy. According to Sabiston’s Textbook of Surgery juvenile polyp is very common between 4 and 14 years of age. There is no malignant potential in these patients. 106. Consider the following statements: Before elective operation ECG may evaluate: 1. Heart rate 2. Atrial fibrillation 3. Heart block 4. Recent myocardial infarction Which of these statements are correct? A. 1, 2 and 4 B. 2, 3 and 4 C. 1 and 3 D. 1, 2, 3 and 4 Ans. D Heart rate, atrial fibrillation, heart block and recent MI can be diagnosed by ECG before elective operation. Besides this conduction block and electrolyte disturbances can also be diagnosed pre-operatively. 107. Which one of the following odontomes is a locally invasive malignant tumour? A. Odontogenic myxoma B. Fibromatous epulis C. Dentigerous cyst D. Ameloblastoma Ans. D (Bailey and Love 23rd ed., p 598) Ameloblastoma is a locally invasive malignant tumour. It may be cystic or solid. Most common site for these to occur is in the third molar region and ramus of mandible. Odontogenic myxoma is a benign odontogenic tumour of dental lamina. 108. Match List-I (Cells) with List-II (Tumours that develop from them) and select the correct answer using the codes given below the Lists: List-I (Cells) List-II (Tumours that develop from them) a. Leydig cells 1. Carcinoid tumour b. β cells 2. Medullary carcinoma c. Parafollicular cells 3. Interstitial cell tumour d. Argentaffin cells 4. Insulinoma Codes: A. a b c d B. a b c d C. a b c d D. a b c d 1 4 2 3 3 2 4 1 1 2 4 3 3 4 2 1 Ans. D Leydig cells produce testosterone. Interstitial cell tumour originates from Leydig cells. β -cells of pancreas secrete insulin. Insulinoma arises from β-cells and secretes insulin. Patient suffers from hypoglycaemia and obesity. 2002.34 Rapid Digest UPSC – Combined Medical Services Examination Medullary carcinoma of thyroid (MTC) is a rare thyroid carcinoma. It arises from parafollicular C cells. These cells secrete calcitonin. MTC is often associated with MEN syndrome. Calcitonin is used for diagnosis as well as to study the response of treatment. Carcinoid tumour arises from argentaffin cells. These tumours secrete serotonin and are associated with carcinoid syndrome. Flushing and diarrhoea are the most important features. 109. Match List-I (Clinical signs) with List-II (Clinical description) and select the correct answer using the codes given below the Lists: List-I (Clinical signs) List-II (Clinical description) a. Ballance’s sign 1. Supraclavicular node in visceral malignancy b. Kehr’s sign 2. Referred pain in left shoulder in splenic trauma c. Cullen’s sign 3. Shifting dullness in flanks in splenic trauma d. Trosier’s sign 4. Periumbilical discoloration in acute pancreatitis Codes: A. a b c d B. a b c d C. a b c d D. a b c d 3 2 1 4 2 3 4 1 2 3 1 4 3 2 4 1 Ans. D Balance sign: Shifting dullness in flanks in splenic trauma. Kehr sign: Referred pain in left shoulder in splenic trauma. Cullen’s sign: Periumbilical discolouration in acute pancreatitis. Grey-Turner sign: Discolouration in both the flanks of abdomen in pancreatitis. Trosier’s sign: Supraclavicular node in visceral malignancy. 110. The ideal temperature of water to cool the burnt surface is: A. 15°C B. 10°C C. 8°C D. 6°C Ans. A (Bailey and Love 23rd ed., p 193) For cooling burnt surface, ideal temperature of cooling water is 15°C but 8 to 25ºC is effective. The burnt area should then be wrapped in any clean linen or plastic ‘cling film’ and patient transported immediately to hospital. Immediate cooling of burnt surface is very important and should continue for 20 minutes. Irrigation with cold water is very valuable in the management of scalds and chemical burns. Avoid hypothermia. Do not use ice. 111. Operation of choice for retrocaval ureter is: A. Cutting and suturing IVC B. Cutting and suturing ureter C. Anderson-Hyenes pyeloplasty D. Ureterocystoplasty Ans. B (Bailey and Love 24th ed., p 1310) In postcaval/retrocaval ureter the right ureter passes behind the IVC instead of lying to the right of it. If this causes obstructive symptoms, the ureter can be divided and rejoined in front of the cava using a long oblique anastomosis without tension. Unusually the retrocaval portion of the ureter is fibrotic and must be excised. Direction: The following 9 (nine) items consist of two statements, one labelled as ‘Assertion A’ and the other labelled as ‘Reason R’. You are to examine these two statements carefully and decide if the ‘Assertion A’ and the ‘Reason R’ are individually true and if so, whether the Reason is a correct explanation of the Assertion. Select your answers to these items using the codes given below and mark your answer sheet accordingly. Codes: A. Both A and R are true and R is the correct explanation of A B. Both A and R are true but R is not a correct explanation of A C. A is true but R is false D. A is false but R is true UPSC Paper-1 2002 2002.35 112. Assertion A : Splenectomised patients are at increased risk of septicaemia. Reason R : Splenectomised patients frequently have an increased white cell and platelet count. Ans. B (Harrison 16th ed., p 709) Splenectomised patients are at increased risk of septicaemia particularly from bacteria with capsules, for e.g., Streptococcus pneumoniae, H. influenzae, and gram negative enteric organisms. This is because of inability to remove opsonized bacteria from the blood and defect in matching antibodies to T cell-independent antigens such as polysaccharide component of bacterial capsule. Immediately after splenectomy there may be leucocytosis (up to 25,000/cumm) and raised platelets (up to 1 × 106/µL) but after 2-3 weeks they become normal. 113. Assertion A : Breast conserving treatment is not applicable for lobular carcinoma of breast. Reason R : Lobular carcinoma is multifocal in origin. Ans. A (Harrison 15th ed., p 577) Lobular carcinoma is multicentric within the same breast. So breast-conserving treatment is not applicable for lobular carcinoma. Though Harrison states that lobular neoplasia may be a premalignant lesion that suggests an elevated risk of subsequent cancer, rather than a form of malignancy itself and aggressive local management seems unreasonable. Moreover approximately 30% of patients who have had adequate local excision of the lesion develop breast cancer over 15 to 20 years. Ipsilateral and contralateral diseases are equally common. 114. Assertion A : Secondary haemorrhage occurs 7-14 days after operation. Reason R : Haemorrhage is due to the slipping of a ligature or dislodgement of a clot. Ans. B (Bailey and Love 24th ed., p 60) Primary haemorrhage occurs at the time of injury or operation. Secondary hemorrhage occurs after 7 to 14 days and is due to infection and sloughing of part of the wall of an artery. Reactionary hemorrhage may follow primary haemorrhage within 24 hours (usually 4 to 6 hours) and is mainly due to rolling (slipping) of a ligature, dislodgement of clot or cessation of reflex vasospasm. The precipitating circumstances are: 1. Rise in blood pressure and the refilling of the venous system on recovery from shock. 2. Restlessness, coughing and vomiting which raise the venous pressure (e.g., reactionary haemorrhage within a few hours of thyroidectomy). 115. Assertion A : Diabetic ulcer is a trophic ulcer. Reason R : It is caused by ischaemia and anaesthesia. Ans. A (Harrison 16th ed., p 2168) The various factors involved in pathogenesis of diabetic foot ulcers are neuropathy (anaesthesia, anhidrosis, altered superficial blood flow), abnormal foot mechanism, peripheral vascular disease (ischaemia) and poor wound healing. 116. Assertion A : H. pylori eradication regimens promote healing and prevents relapse in peptic ulcer disease. Reason R : H. pylori is the only etiological factor in peptic ulcer. Ans. C (Harrison 16th ed., p 1754) H. pylori is strongly associated with peptic ulcer disease but the exact mechanism by which it causes ulcer is not yet clear. It is of course not the only aetiological factor. Eradication of H. pylori is strongly recommended in PUD. It drastically decreases the ulcer recurrence rates. According to 16th edition of Harrison page 1754 “....Documented eradication of H. pylori in patients with PUD is associated with a dramatic decrease in ulcer recurrence to 4% (as compared to 59%) in GU patients and 6% (compared to 67%) in DU patients....” 117. Assertion A : A person who hears voices talking to him even when no one is present is likely to be suffering from schizophrenia. Reason R : Primary delusions are characteristic of schizophrenia. 2002.36 Rapid Digest UPSC – Combined Medical Services Examination Ans. B The assertion is nothing but the classical description of auditory hallucination, which is typically seen in schizophrenia. The reason is also correct but it is about delusion and not hallucination and hence the answer is B. Perception without stimuli (hallucination) is common in schizophrenia. Auditory hallucination is by far the most frequent. Only the third person hallucination (voices heard arguing) is characteristic of schizophrenia. A person who hears voices talking to him even when no one is present is likely to be suffering from schizophrenia. Primary delusion also known as autochthonous delusions, these are characteristics of schizophrenia. Thus both the statements are correct, but ‘R’ is not correct explanation of ‘A’. 118. Assertion A : Acute gouty arthritis is a common side effect of pyrazinamide therapy. Reason R : Pyrazinamide can cause hyperuricemia Ans. D (Harrison 16th ed., p 949) Pyrazinamide causes hyperuricaemia commonly but the incidence is probably reduced by concurrent rifampicin therapy in TB. Clinical gouty arthritis is rare. 119. Assertion A : Hyperkalemia is not a feature of ACTH deficiency (secondary adrenal insufficiency). Reason R : ACTH increases potassium reabsorption by the distal renal tubule. Ans. C (Harrison 16th ed., p 2143) In secondary adrenocortical insufficiency mineralocorticoid secretion is normal. Hence Na+ and K+ homeostasis remain normal. Hyperkalaemia and hyponatraemia suggest primary adrenocortical insufficiency. ACTH plays a role in K+ homeostasis but the role is very minor because ACTH stimulates mineralocorticoid release very minimally. 120. Assertion A : In complete transposition of the great arteries, compatibility with life requires that a communication exists between the pulmonary and systemic circulation. Reason R : In complete transposition of great arteries, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Ans. A (Harrison 16th ed., p 1388; Bailey and Love 24th ed., p 907-908) In complete transposition of great arteries aorta arises from right ventricle to the right of and anterior to the pulmonary artery, which emerges from the LV. This results in two separate and parallel circulations and some communication between them must exist after birth to sustain life. Most patients have an interatrial communication. Two third have a patent ductus arteriosus and about one third have an associated ventricular septal defect. Transposition is more common in males and account for 10% of cyanotic heart disease. It is cyanotic congenital heart disease with increased pulmonary blood flow. Operation done are Mustard/Senning operation so that systemic venous blood is directed to the mitral valve and thence to the LV and pulmonary artery, while the pulmonary venous blood is directed through the tricuspid valve and RV to the aorta. Palliation was achieved by creating an ASD (Blalock). According to Bailey and Love 23rd p 819, initial treatment for this condition is balloon septostomy (Rashkind). Remember the following important points about ‘transposition of great arteries’: It is the most common cause of cyanosis from a congenital cardiac defect discovered in the newborn period. Most obvious presentation is severe central cyanosis presenting in first 48 hours of life. CHF is the most common cause of death. Chest radiograph shows pulmonary plethora, with the heart having an ‘egg on its side’ appearance, with a small pedicle (aorta in front of pulmonary artery).