UPSC PAPER-2 PAPER-2 1998 1. Which of the following indicators are consolidated in computing the ‘physical quality of life index’ (PQLI)? 1. Infant mortality 2. Economic status 3. Life expectancy at age one 4. Literacy 5. Maternal mortality Select the correct answer using the codes given below: Codes: A. 2, 3 and 5 B. 1, 2 and 4 C. 1, 3 and 4 D. 1, 4 and 5 Ans. C (Park 18th ed., p 16) The ‘physical quality of life index’ consolidates three indicators, viz., infant mortality, life expectancy at age one and literacy. These three components measure the results rather than inputs. For each component, the performance of individual countries is placed on a scale of 0 to 100. The composite index is calculated by averaging the three indicators, giving equal weight to each of them. The resulting PQLI thus is also scaled 0 to 100. It does not measure economic growth; it measures the results of social, economic and political policies. 2. Prevention of emergence of risk factors is: A. Primordial prevention B. Primary prevention C. Secondary prevention D. Tertiary prevention Ans. A (Park 18th ed., p 37) Primordial prevention is prevention of emergence or development of risk factors in countries or population groups in which they have not yet appeared. The efforts in it are directed towards discouraging children from adopting harmful lifestyles. The main intervention is through individual and mass education. 3. Which one of the following pairs is not correctly matched? A. Serial interval – Time interval between the onset of primary case and secondary case B. Generation time – Time required for the completion of desired family size by an eligible couple C. Median incubation period – Time required for 50% of the case to occur, following exposure D. Latent period – The period from disease initiation to disease detection Ans. B (Park 18th ed., p 91-92) Serial interval: The gap between the onset of primary case and the secondary case. Latent period: Used in non infectious diseases, equivalent to incubation period and defined as period from disease initiation to disease detection. Generation time: Interval of time between receipt of infection by a host and maximal infectivity of that host. Incubation period: The time interval between invasion by an infectious agent and appearance of the first sign or symptom of the disease in question. Median incubation period is defined as the time required for 50% of cases to occur following exposure. 1998.38 Rapid Digest UPSC – Combined Medical Services Examination 4. Consider the following types of epidemics: 1. Common source epidemics 2. Periodic epidemics 3. Propagated epidemics 4. Slow epidemics The three major types of epidemics would include: A. 1, 2 and 3 B. 1, 3 and 4 C. 2, 3 and 4 D. 1, 2 and 4 Ans. B (Park 18th ed., p 58) Epidemiologists have recognized three kinds of time trends or fluctuations in disease occurrence. 1. Short term fluctuations: The best example of short term fluctuation in occurrence of disease is an epidemic. Three major types of epidemics may be distinguished. a. Common source epidemic: – Single exposure or point source epidemics. – Continuous or multiple exposure epidemics. b. Propagated epidemics: – Person to person. – Arthopod vector. – Animal reservoir. c. Slow (modern) epidemics. 2. Periodic fluctuations: a. Seasonal trend. b. Cyclic trend. 3. Long term or secular trends. 5. The following table gives the results of a screening test: Result of screening test Gold standard Total Disease No disease Positive 350 100 450 Negative 150 100 250 Total 500 200 700 The positive predictive value of the test is: A. 40.0% B. 50.0% C. 70.0% D. 77.7% Ans. D (Park 18th ed., p 116) True positive Predictive value of a positive test = True positive + false positive × 100 Aplying the data in question 350 = × 100 350 + 100 350 = × 100 = 77.7% 450 6. Consider the following statements: Propagated epidemic curve is characterised by: 1. Many peaks 2. More than one incubation period 3. Steep and abrupt onset 4. Prolonged epidemic tail Of these statements: A. 1 and 4 are correct B. 2 and 3 are correct C. 1, 2 and 4 are correct D. 1, 2, 3 and 4 are correct UPSC Paper-2 1998 1998.39 Ans. C (Park 18th ed., p 59) A propagated epidemic is most often of infectious origin and results from person to person transmission of an infectious agent. The epidemic usually shows a gradual rise and tails off over a much longer period of time. Transmission continues until the number of susceptibles is depleted or susceptible individuals are no longer exposed to infected persons or intermediary vectors. The speed of spread depends upon herd immunity, opportunities for contact and secondary attack rate. They are more likely to occur where large number of susceptibles are aggregated or where there is a regular supply of new susceptible individuals (e.g., birth, immigrants) lowering herd immunity. 7. Vitamin D is synthesized by the body by the action of ultraviolet radiation of the sun on: A. Calciferol B. Cholecalciferol C. 7-dehydrocholesterol D. Ergosterol Ans. C (Nelson 17th ed., p 186; Park 18th ed., p 444) Vitamin D3 is naturally present in human skin in the provitamin stage as 7-dehydrocholesterol. It is activated photochemically by ultraviolet radiation to cholecalciferol and transferred to the liver. These irradiated sterols are hydroxylated in the liver to 25-OH-cholecalciferol and, subsequently, in the renal cortical cells to 1, 25- dihydroxycholecalciferol, which functions as the main hormone. 8. Match List-I with List-II and select the correct answer using the codes given below the Lists: List-I (Disease) List-II (Toxin) a. Neurolathyrism 1. Sanguinarine b. Epidemic dropsy 2. Beta oxalyl amino alanine c. Cirrhosis of liver 3. Pyrolizidine alkaloids d. Endemic ascitis 4. Aflatoxins 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 2 1 4 3 1 2 3 4 1 2 4 3 Ans. B (Park 18th ed., p 467, 479) Neurolathyrism results from consumption of khesari dhal (Lathyrus sativus). The toxin present in lathyrus seeds is beta oxalyl amino alanine (BOAA). Aflatoxin B1 has also been detected in samples of breast milk and urine collected from children suffering from infantile cirrhosis. Attempts are also being made to relate aflatoxin with human liver cirrhosis. Epidemic dropsy is due to contamination of mustard oil with argemone oil. It is due to toxic alkaloid, sanguinarine from argemone oil. This toxic substance interferes with oxidation of pyruvic acid which accumulates in the blood. The disease may occur at all ages except breastfed infants. Endemic ascites results from contamination of millet Panicum miliare (locally known as Gondhli) which gets contaminated with weed seeds of Crotalaria (locally known as Jhunjhunia). Jhunjhunia seeds contain pyrrolizidine alkaloids which are hepatotoxin. 9. All of the following statements about niacin are true except: A. It is required by the body for the utilization of carbohydrate and for tissue respiration B. It is widely distributed in animal and plant foods C. It is not removed from the cereal in process of milling D. Its deficiency causes pellagra Ans. C (Park 18th ed., p 446, 453) Niacin is essential for the metabolism of carbohydrate, fat and protein. It is also essential for the normal functioning of the skin, intestine and nervous system. Foods rich in niacin and/or tryptophan are liver, kidney, meat, poultry, fish, legumes and groundnut. Pellagra is a preventable disease. A good mixed diet containing milk (rich in tryptophan but poor in niacin) and/ or meat is universally regarded as an essential part of prevention and treatment. The milling process deprives the rice grain of its nutritive elements. The losses may be up to 15 percent of protein, 75 percent thiamine and 60 percent riboflavin and niacin. 1998.40 Rapid Digest UPSC – Combined Medical Services Examination 10. Which one of the following is the best indicator of protein quality for recommending the dietary protein requirement? A. Protein efficiency ratio B. Biological value C. Digestibility coefficient D. Net protein utilization Ans. D (Park 18th ed., p 440, 459; Essential Preventive Medicine OP Ghai, Piyush Gupta, p 108, 119; Textbook of Community Medicine by Kulkarni p 476) The quality of protein is assessed by comparison to the reference protein which is usually egg protein. It can be evaluated by amino acid score, net protein utilization, biological value, digestibility coefficient, protein efficiency ratio. Net protein utilization (NPU): It is a product of digestibility coefficient and biological value divided by 100. It gives a more complete expression of protein quality. It is a biological method that requires special laboratory facilities. Nitrogen retained by the body NPU = × 100 Nitrogen intake In calculating protein quality, 1 g of protein is assumed to be equivalent to 6.25 g of N. The NPU of protein of Indian diets varies between 50 and 80. It is the proportion of ingested protein that is retained in the body under specified conditions for maintenance and/or growth of tissues. A knowledge of the amino acid content of protein is not sufficient for evaluation of protein quality. Information is also required about the digestibility and suitability to meet the protein needs of the body. The parameters used for such an evaluation include the estimation of biological value, digestibility coefficient, protein efficiency ratio and net protein utilization (NPU). The NPU is considered of more practical value because it is the product of biological value and digestibility coefficient divided by 100. In exact terms, it is the ‘proportion of ingested protein that is retained in the body under specified conditions for the maintenance and/or growth of the tissues’. 11. Consider the following cause of neonatal mortality: 1. Congenital anomalies 2. Birth injury 3. Convulsion 4. Hypothermia 5. Asphyxia 6. Sepsis The three most important causes of early neonatal mortality would include: A. 4, 5 and 6 B. 1, 2 and 5 C. 3, 4 and 6 D. 1, 3 and 5 Ans. A (Park 18th ed., p 416; Journal Neonatology 2005; 19(1):4-7) According to Journal Neonatology “….Neonatal sepsis including septicemia and pneumonia emerged as the most common cause, figuring in 52% of the deaths, followed by birth asphyxia (20%) and prematurity (15%).…” Neonatal deaths are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth. Neonatal mortality rate is the number of neonatal deaths in a given year per 1000 live births in that year. The causes of neonatal mortality are multifactorial – low birth weight, birth injury and difficult labour, postnatal asphyxia, atelectasis, congenital malformations, haemolytic diseases of newborn, conditions of placenta and cord, diarrhoeal diseases, acute respiratory infections and tetanus. Neonatal mortality is a measure of the intensity with which ‘endogenous factors’ (e.g., low birth weight, birth injuries) affect infant life. The neonatal mortality is directly related to the birth weight and gestational age; the lighter or more immature the baby, the higher the death rate. In India, 55 to 60 percent of infant deaths occur within neonatal period. Of these more than half may die during the first week of birth, first 24 hours being the time of greatest risk. Neonatal mortality rate for the year 1999 was 49 per 1000 live births in rural areas, 28 in urban areas and about 45 in the whole country. 12. Maternal mortality refers to maternal deaths from causes related to or aggravated by pregnancy and its management during: A. Pregnancy, child birth or first seven days after delivery B. Child birth or first fourteen days after delivery C. First 28 days after delivery D. Pregnancy, child birth or first 42 days after delivery UPSC Paper-2 1998 1998.41 Ans. D (Park 18th ed., p 412) Maternal death is defined as ‘the death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or, its management but not from accidental or incidental causes. Maternal mortality rate measures the risk of women dying from ‘puerperal causes’ and is defined as: Total no. of female deaths due to complications of pregnancy, childbirth or within 42 days of delivery from puerperal causes in an area during a given year = × 1000 Total no. of live births in the same area and year Ideally the denominator should include all deliveries and abortions. About 80% of maternal deaths are due to direct obstetric causes i.e., obstetric complications of pregnancy, labour and puerperium to interventions or incorrect treatment. According to RGI estimates for the year 2000, maternal mortality rate for India was 407 per 1,00,000 live births. The major causes of maternal morality during 1998 were antenatal and postnatal haemorrhage (29 percent), anaemia (19 percent), puerperal sepsis (16 percent), obstructed labour (10 percent), abortion (9 percent), toxaemia (8 percent) and unclassifiable (9 percent). 13. The guidelines under the CSSM programme recommended that a low birth weight baby with good sucking and without any signs of illness can be managed at home with special care even if the birth weight is as low as: A. 2200 grams B. 2000 grams C. 1800 grams D. 1500 grams Ans. C (National CSSM Programme Training Manual, Ministry of Health and Family Welfare, Govt. of India; Park 18th ed., p 397) According to Government of India training manual, babies between 1800 to 2500 grams can be managed at home provided they have no signs of illness. However they will need special care at home. All newborn babies less than 1800 grams should be referred for specialist care. LBW babies who are sucking poorly at the breast, are hypothermic or have any of the following signs of illness should also be referred for specialist care: 1. Lethargy. 2. Fast breathing and/or chest indrawing. 3. Apnoea. 4. Abdominal distension. 5. Cyanosis. 6. Pathological jaundice. 7. Diarrhoea. 8. Convulsions. 14. Which one of the following body measurements is the best for a rapid screening of PEM? A. Weight for age B. Height for age C. Weight for height D. Mid upper arm circumference Ans. A (Park 18th ed., p 403, 463) The first indicator of PEM is under weight for age. The most practical method to detect this, which can be employed even by field health workers is to maintain growth charts. Weight is the most sensitive measure of growth and any deviation from ‘normal’ can be detected easily by comparison with reference curve. Arm circumference yields a relatively reliable estimation of body’s muscle mass, the reduction of which is one of the most striking mechanisms by which the body adjusts to inadequate energy intakes. Arm circumference cannot be used before the age of one year; between ages one and five years, it hardly varies. 15. Which one of the following is used as an adsorbent in DPT vaccine? A. Aluminium phosphate B. Thiomersal C. Alum D. Zinc sulphate Ans. A (Park 18th ed., p 135; Nelson 16th ed., p 889) 1998.42 Rapid Digest UPSC – Combined Medical Services Examination Diphtheria toxoid is prepared by formaldehyde treatment of toxin, standardized for potency, and adsorbed to aluminum salts (aluminium phosphate or hydroxide), which enhance immunogenicity. Two preparations of diphtheria toxoids are formulated according to the limit of flocculation (Lf) content that is a measure of the quantity of toxoid. The pediatric preparation (i.e., DTaP, DT, DTP) contains 6.7-12.5 Lf units of diphtheria toxoid per 0.5 mL dose; the adult preparation (i.e., Td) contains 2 Lf units of toxoid per 0.5 mL dose. 16. ‘Pearl index’ is a measure of: A. Malnutrition in under five children B. The level of mosquito larvae in household containers C. The effectiveness of a contraceptive method D. Risk factor in coronary heart disease Ans. C (Park 18th ed., p 375) Contraceptive efficacy is generally assessed by measuring the number of unplanned pregnancies that occur during a specified period of exposure and use of a contraceptive method. The two methods that have been used to measure contraceptive efficacy are the Pearl index and life table analysis. Pearl index is used for evaluation of use-effectiveness. The Pearl index is defined as the number of ‘failures per 100 women-years of exposure (HWY)’. This rate is given by the formula: Total accidental pregnancies Failure rate per HWY = × 1200 Total months of exposure The total accidental pregnancies shown in the numerator must include every known conception, whatever its outcome. The Pearl index is usually based on a specific exposure (usually one year) and therefore, fails to accurately compare methods at various durations of exposure. This limitation is overcome by using the method of life-table analysis. Life table analysis determines the probability of pregnancy while practicing a method of contraception during a fixed interval. It calculates a failure rate for each month of use and then a cumulative women months of use are calculated. 17. The number of children in 0 to 4 years of age per 1000 women of child bearing age (15 to 44 or 49 years) is defined as: A. General fertility rate B. Total fertility rate C. Gross reproduction rate D. Child to woman ratio Ans. D (Park 18th ed., p 357) Child-woman ratio is the number of children 0-4 years of age per 1000 women of child bearing age, usually defined as 15 to 44 or 49 years of age. This ratio is used where birth registration statistics either do not exist or are inadequate. It is estimated through data derived from censuses. 18. The percentage of eligible couples practising family planning in India is: A. 15 B. 30 C. 45 D. 55 Ans. C (Park 18th ed., p 360) An ‘eligible couple’ refers to a currently married couple wherein the wife is in the reproductive age, which is generally assumed to be between the ages of 15 and 45. Couple protection rate (CPR) is defined as the percent of eligible couples effectively protected against childbirth by one or the other approved methods of family planning. As of 31st March 2000, about 79 million couples (46.2 percent of eligible couples in the reproductive age group 15 to 44 years) were effectively protected against conception by one or the other family planning method. Sterilization accounts for over 60 percent of effectively protected couples. Demographic goal of net production rate (NRR) = 1 can be achieved only if the CPR exceeds 60 percent. 19. Oral contraceptives are contraindicated in all of the following conditions except: A. Women above 42 years of age B. Lactating women with 8 months’ baby C. Women with mass in breast D. Women with severe headache Ans. B (DC Dutta Textbook of Gynaecology 3rd ed., p 446; Ashok Kumar Essentials of Gynaecology 1st ed., p 14) Lactating women with 8-month baby may be prescribed OCP. UPSC Paper-2 1998 1998.43 Contraindications to OCP Absolute Relative 1. Circulatory diseases (past or present): Obesity. Arterial/venous thrombosis. Varicosities. Severe HT. Epilepsy. Valvular heart disease. Bronchial asthma. Ischaemic heart disease. Depression and fluctuation of mood. Angina. Nursing mothers in first 6 months. Hyperlipidaemia. Smoking. Migraine. 2. Diseases of liver: Active liver disease. History of cholestatic jaundice in pregnancy. Liver adenoma and carcinoma. 3. Others: Pregnancy. Undiagnosed genital tract bleeding. Oestrogen dependent neoplasms e.g., breast cancer. 20. Fertilized ovum reaches the uterine cavity in: A. 2 to 3 days B. 4 to 5 days C. 8 to 10 days D. 11 to 15 days Ans. B (DC Dutta Textbook of Obstetrics 6th ed., p 22) Morula after spending 3 days in uterine tube enters the uterine cavity through the narrow uterine ostium on the 4th day in 16-64 cell stage. Remember the following important points commonly asked in examination: Implantation occurs on 6th day which corresponds to 20th day of a regular menstrual cycle. Ovulation occurs 16-24 hours after LH surge. Time required for spermatogonium to develop into a mature spermatozoa is about 61 days. Capacitation takes about 2-6 hours. 21. For proper functioning, oxidation pond requires: A. Algae, sunlight and ferns B. Algae, scavenging bacteria and sunlight C. Algae, saprophytic bacteria and sunlight D. Algae, human pathogenic bacteria and sunlight Ans. B (Park 18th ed., p 572) Oxidation pond is a cheap method of sewage treatment. They are useful for purifying sewage in small communities. The oxidation pond is an open, shallow pool 1 to 1.5 metre deep with an inlet and outlet. To qualify as an oxidation pond, there must be the presence of: a. Algae. b. Certain types of bacteria which feed on decaying organic matter. c. Sunlight. The organic matter in the sewage is oxidized by bacteria to simple chemical compounds such as carbon dioxide, ammonia and water. The algae, with the help of sunlight, utilize the carbon dioxide, water and inorganic minerals for their growth. Oxygen for oxidation is mostly derived from the algae which liberates oxygen under the influence of sunlight. The oxidation ponds are predominantly aerobic during sunshine hours as well as some hours of the night. In the remaining hours of the night, the bottom layers are generally anaerobic. 1998.44 Rapid Digest UPSC – Combined Medical Services Examination 22. Match List-I (Instrument) with List-II (Parameter measured) and select the correct answer using the codes given below the Lists: List-I (Instrument) List-II (Parameter measured) a. Sling psychrometer 1. Radiant heat b. Kata thermometer 2. Low air velocities c. Anaemometer 3. High wind velocities d. Globe thermometer 4. Relative humidity Codes: A. a b c d B. a b c d C. a b c d D. a b c d 2 4 3 1 2 4 1 3 4 2 3 1 4 2 1 3 Ans. C (Park 18th ed., p 555, 557) The globe thermometer is used for the direct measurement of the mean radiant temperature of the surroundings. The globe thermometer registers a higher temperature than the ordinary air temperature thermometer because it is affected both by the air temperature and radiant heat. The difference between the globe thermometer temperature and that of the ordinary dry bulb thermometer is a measure of the radiant heat. Kata thermometer was originally devised for measuring the ‘cooling power’ of the air. It is now largely used as an anemometer for recording low air velocities. By sling psychrometer, the relative humidity of the air may be obtained. By anemometer, the air velocity is measured. Wind direction is observed by an instrument called the wind vane. 23. Citrate is added to conventional oral rehydration solution (ORS) in order to: A. Improve sodium chloride absorption B. Correct acidosis C. Increase its shelf life D. Improve glucose absorption Ans. C (Park 18th ed., p 180; www.who.int/child-adolescent-health/New-Publication) Actually the choices A, B and C are correct. However the most appropriate choice is choice C. According to WHO publication and other reputed journals the main reason for trisodium citrate ORS is low shelf life of bicarbonate ORS. In hot and humid conditions bicarbonate reacts with glucose and the ORS is destroyed. To prevent this and to prolong the shelf life of ORS, trisodium citrate ORS was recommended by WHO. Citrate is a potential bicarbonate and hence corrects acidosis. The inclusion of trisodium citrate in place of sodium bicarbonate in the ORS has made the product more stable. Moreover, the use of ORS citrate results in less stool output especially in high output diarrhoea (e.g., cholera), probably because of a direct effect of trisodium citrate in increasing intestinal absorption of sodium and water. 24. Out of five members of a family, four developed sudden onset of vomiting, abdominal cramps and diarrhoea in the middle of the night after dinner at 9.30 PM which had salads, custard, milk and milk products in the menu. The most likely type of food poisoning is: A. Salmonella B. Staphylococcal C. Botulism D. Clostridium perfringens Ans. B (Park 18th ed., p 190) Most likely cause is staphylococcal food poisoning. It results from enterotoxins of certain strains of coagulase positive Staphylococcus aureus. The foods involved are salads, custards, milk and milk products which get contaminated by staphylococci. Incubation period is 1 to 6 hours. The incubation period is short because of ‘preformed’ toxin. The toxin is heat resistant and it can remain in food after the organisms have died. The illness manifests by sudden onset of vomiting, abdominal cramps and diarrhoea. Death is uncommon. Salmonella food poisoning: Species most often incriminated are S. typhimurium, S. cholera-suis and S. enteritidis. Man gets infection from farm animals and poultry – through contaminated meat, milk and milk products, sausages, custards, egg and egg products. Incubation period is 12 to 24 hours. Causative organisms multiply in intestine on ingestion and give rise to acute enteritis and colitis. The onset is generally sudden with chills, fever, nausea, vomiting and profuse watery diarrhoea lasting 2 to 3 days. Mortality is about 1 percent. UPSC Paper-2 1998 1998.45 Cl. perfringens food poisoning is associated with ingestion of meat, meat dishes and poultry. Incubation period is 6 to 24 hours, with a peak from 10 to 14 hours. Poisoning occurs because spores are able to survive cooking and if the cooked meat and poultry is not cooled enough, they will germinate. The organisms produce a variety of toxins. Most common symptoms are diarrhoea, abdominal cramps and little or no fever, occurring 8 to 24 hours after consumption of food. Nausea and vomiting are rare. Botulism results from exotoxin of Clostridium botulinum generally type A, B or E. It kills two thirds of its victims. The food most frequently responsible for botulism are home preserved foods such as home canned vegetables, smoked or pickled fish, home made cheese and similar low acid foods. Incubation period is 12 to 24 hours. Preformed toxin in food, formed under anaerobic conditions, acts on the parasympathetic nervous system. Gastrointestinal symptoms are slight. Prominent symptoms are dysphagia, diplopia, ptosis, dysarthria, blurring of vision, muscle weakness and even quadriplegia. Fever is generally absent and consciousness is retained. Death occurs in 4 to 8 days due to respiratory or cardiac failure. Bacillus cereus food poisoning is due to spores which survive cooking and germinate and multiply rapidly when the food is held at favourable temperatures. It produces at least 2 distinct enterotoxins, causing 2 distinct forms of food poisoning. One is diarrheal form (incubation period 12 to 24 hours) and other is emetic form (incubation period 1 to 6 hours). Recovery occurs within 24 hours. Toxins are preformed and stable. 25. Which of the following are the major signs in AIDS? 1. Weight loss of more than 10% body weight 2. Chronic and progressive ulcerative herpes simplex 3. Diarrhoea of more than one month duration Select the correct answer using the codes given below: Codes: A. 1 and 3 B. 1 and 2 C. 2 and 3 D. 1, 2 and 3 Ans. A (Park 18th ed., p 277) WHO clinical case definition for AIDS surveillance: For the purpose of AIDS surveillance an adult or adolescent (> 12 years of age) is considered to have AIDS if at least 2 of the following major signs are present in combination with at least 1 of the minor signs listed below, and if these signs are not known to be due to a condition unrelated to HIV infection. Major signs Weight loss ≥ 10% of body weight. Chronic diarrhoea for more than 1 month. Prolonged fever for more than 1 month (intermittent or constant). Minor signs Persistent cough for more than 1 montha,b. Generalized pruritic dermatitis. History of herpes zoster. Oropharyngeal candidiasis. Chronic progressive or disseminated herpes simplex infection. Generalized lymphadenopathy. The presence of either generalized Kaposi sarcoma or cryptococcal meningitis is sufficient for the diagnosis of AIDS for surveillance purposes. a. For patients with tuberculosis, persistent cough for more than 1 month should not be considered as a minor sign. b. Indicates changes from the 1985 provisional WHO clinical case definition for AIDS. Not all the HIV-related opportunistic diseases are covered in the AIDS definition. 26. Risk of perinatal transmission of HIV from HIV positive mother to her child is about: A. 90% B. 60% C. 30% D. Less than 5% Ans. C (Park 18th ed., p 275) 1998.46 Rapid Digest UPSC – Combined Medical Services Examination HIV may pass from an infected mother to her foetus, through the placenta or to her infant during delivery or by breast feeding. In the absence of any intervention, rates of this form of transmission can vary from 15 to 30% without breast feeding and reaches as high as 45% with prolonged breast feeding. Transmission during the peripartum period accounts for one-third to two-thirds of overall numbers infected depending on whether breast feeding transmission occurs or not. The risk of infection is higher if the mother is newly infected or if she has already developed AIDS. Transmission of HIV from mother to child can be prevented almost entirely by triple drug combination antiretroviral drug prophylaxis, elective caesarean section before onset of labour and rupture of membranes, and by refraining from breast feeding. 27. As per the recommendations of the WHO the multidrug regimen for paucibacillary case of leprosy is: A. Rifampicin 600 mg daily plus dapsone 300 mg daily for six months B. Rifampicin 600 mg once a month plus dapsone 300 mg once a month for six months C. Rifampicin 600 mg once a month for six months and dapsone 300 mg daily for six months D. Rifampicin 600 mg once a month for six months and dapsone 100 mg daily for six months Ans. D (Park 18th ed., p 261) According to WHO recommendation standard regimen for paucibacillary leprosy for adults is: Rifampicin: 600 mg once a month for 6 months, supervised. Dapsone: 100 mg (1-2 mg/kg of body weight) daily for 6 months, self-administered. The standard treatment regimen for children aged 10 to 14 years in paucibacillary leprosy is: Rifampicin: 450 mg once a month supervised for 6 months. Dapsone: 50 mg daily, self administered for 6 months. Children under the age 10 years should receive appropriately reduced doses of the above drugs. Adequate treatment for paucibacillary cases implies that the patient has received 6 monthly doses of combined therapy within 9 months. 28. Match List-I (Cancer related organism) with List-II (Type of cancer) and select the correct answer using the codes given below the Lists: List-I (Cancer related organism) List-II (Type of cancer) a. Human papilloma virus 1. Liver cancer b. Epstein Barr virus 2. Cervical cancer c. Aspergillus flavus 3. Bladder cancer d. Schistosomia haematobium 4. Burkitt’s lymphoma Codes: A. a b c d B. a b c d C. a b c d D. a b c d 2 4 3 1 4 2 1 3 2 4 1 3 4 2 3 1 Ans. C (Robbins 6th ed., p 309, 311-313, 1049) Human papilloma virus (e.g., 1, 2, 4 and 7) definitely cause benign squamous papillomas (warts) in humans. Human papilloma viruses (HPV) have also been implicated in the genesis of squamous cell carcinoma of the cervix and anogenital region (cervical condylomata) and precancerous lesions. Specific HPV are associated with cervical cancer (high risk) versus condylomata (low risk); low risk types include types 6, 11, 42 and 44 and high risk types include 16, 18, 31, 33 and 35. Some strains of Aspergillus flavus produce hepatic carcinogen aflatoxin B1 (mycotoxin) and produces hepatocellular carcinoma. It cause mutation at codon 249 in the tumour suppressor gene p53. Epstein Barr virus is the causative agent of Burkitt’s lymphoma. Schistosoma haematobium, a parasite is strongly associated with both squamous cell (70%) and transitional cell (30%) bladder cancer. See also Q 40 paper 2 UPSC 1997. 29. All of the following are the well-established modifiable risk factors of coronary heart diseases except: A. Cigarette smoking B. Drinking beverages C. High blood pressure D. Elevated serum cholesterol UPSC Paper-2 1998 1998.47 Ans. B (Park 18th ed., p 289) The aetiology of CHD is multifactorial. Some of the risk factors are modifiable, others immutable. Presence of any one of the risk factors places an individual in a high risk category for developing CHD. The greater is the number of risk factors present, the more likely one is to develop CHD. Table: Risk factors for CHD. Not modifiable Modifiable Age Cigarette smoking Sex High blood pressure Family history Elavated serum cholesterol Genetic factors Diabetes Personality Obesity Sedentary habits Stress 30. Match List-I (Occupational disease) with List-II (Agents/factors) and select the correct answer using the codes given below the Lists: List-I (Occupational disease) List-II (Agents/factors) a. Byssinosis 1. Asbestos dust b. Anthracosis 2. Polyvinyl chloride c. Lung cancer 3. Cotton dust d. Angiosarcoma of the liver 4. Coal dust Codes: A. a b c d B. a b c d C. a b c d D. a b c d 4 3 1 2 3 4 1 2 4 3 2 1 3 4 2 1 Ans. B (Robbins 6th ed., p 309; Park 18th ed., p 609) Occupational exposure to asbestos has been associated with an increased incidence of bronchogenic carcinomas, mesotheliomas and gastrointestinal cancers (esophagus, stomach and large intestine). Polyvinyl chloride, formed from monomer vinyl chloride, leads to hemangiosarcoma of the liver in workers exposed to this chemical. Byssinosis, is due to inhalation of cotton fibre dust over long periods of time. Anthracosis results from exposure to coal dust. 31. In a community where marriages are predominantly consanguineous, the genetic picture that would emerge is: A. Predominance of genotypes B. Predominance of phenotypes C. Non-occurrence of genetic mutations D. More or less equal distribution of genotypes and phenotypes Ans. B (Robbins 6th ed., p 145; Park 18th ed., p 623; Lesson Seventeen: Patterns of Single Gene Inheritence Dr. Jamie Love) The term genotype refer to the total genetic constitution of an individual and the term phenotype to the outward expression of the genetic constitution. In consanguineous marriages i.e., marriages between blood relatives, there is an increased risk in the offspring of traits controlled by recessive genes and those determined by polygenes. Examples are albinism, alkaptonuria, phenylketonuria etc. The autosomal recessive disorders are more common in the consanguineous marriages. The following features apply to most of the autosomal recessive disorders: The expression of the defect tends to be more uniform than in autosomal dominant disorders. Complete penetrance is common. Although new mutations for recessive disorders do occur, they are rarely detected clinically. Consanguineous relationships increase homozygosity and so there is a predominance of phenotypes in these families. 1998.48 Rapid Digest UPSC – Combined Medical Services Examination 32. In the clinicosocial studies of patients, social equilibrium would mean the: A. Equilibrium maintained by the different social institutions in the community B. Equilibrium maintained by the patient with the external forces trying to disturb it C. Harmonious and correct relationship between the patient and the doctor D. Harmony or equilibrium maintained by the patient and his family with the rest of the society Ans. A In clinicosocial studies of patients, social equilibrium would mean the equilibrium maintained by the different social institutions in the community. According to Encyclopaedia Britannica “....social equilirium is a theoretical state of balance in a social system referring both to an internal balance between interrelated social phenomena and to the external relationship the system maintains with its environment.....” 33. The incidence of mental illness is the maximum if the causal factors affect a particular period of life. The vulnerable period is: A. Perinatal period B. First five years of life C. School age D. Adolescence Ans. B (Park 18th ed., p 633) The roots of mental health are in early childhood i.e., first 5 years of life. The infant and young child should experience a warm, intimate and continuous relationship with his mother and father. It is in this relationship where underlies the development of mental health. 34. In the critical path method of network analysis, the critical path is the: A. Shortest B. Longest C. Cheapest D. Costliest Ans. B (Park 18th ed., p 670) Network analysis is a graphic plan of all events and activities to be completed in order to reach an end objective. It brings greater discipline in planning. The two common types of network technique are: a. PERT (programming evaluation and review technique) is a management technique which makes possible more detailed planning and more comprehensive supervision. The essence of PERT is to construct an arrow diagram. The diagram represents the logical sequence in which events must take place. It is possible with such a diagram to calculate the time by which each activity must be completed, and to identify those activities that are critical. PERT is a useful management technique which can be applied to a great variety of projects. It aids in planning, scheduling and monitoring the projects. It allows better communication between the various levels of management, it identifies potential problems; it furnishes continuous, timely progress reports; it forms a solid foundation upon which to build an evaluation and checking system. b. Critical path method (CPM): The longest path of the network is called ‘critical path’. If any activity along the critical path is delayed, the entire project will be delayed. 35. Which of the following sets of village level workers bridge the gap between the government agencies and the people in health care delivery? A. Male health workers, female health workers B. Village health guides, trained dais C. Male health supervisor, female health supervisor D. Anganwadi workers, village agricultural workers Ans. B (Park 18th ed., p 685, 695) Primary health care is the first level of contact between the individual and the health system where essential health care (primary health care) is provided. A majority of prevailing health complaints and problems can be satisfactorily dealt with at this level. This level of care is closest to the people. In the Indian context, this care is provided by the primary health centres and their subcentres, through the agency of multipurpose health workers, village health guides and trained dais. Besides providing primary health care, the village health teams bridge the cultural and communication gap between the rural people and organized health sector. UPSC Paper-2 1998 1998.49 One of the basic tenets of primary health care is universal coverage and equitable distribution of health resources. That is, health care must penetrate into the farthest reaches of rural areas and that everyone should have access to it. To implement this policy at village level the following workers are involved – village health guides, trained local dais and anganwadi workers. These workers serve as links betwen the community and the government infrastructure. 36. All of the following are the principles of primary health care except: A. Social equity B. Intersectoral coordination C. Speciality services D. Community participation Ans. C (Park 18th ed., p 28) Primary health care is defined as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and famiiles in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination. The primary health care approach is based on principles of social equity, nationwide coverage, self reliance, intersectoral coordination and people’s involvement in the planning and implementation of health programmes in pursuit of common health goals. 37. All of the following statements about eradication programme are true except: A. There is complete interruption of disease transmission in the entire area of the community B. Eradication programme is over once the disease has been certified as having been eradicated C. Case finding is of secondary importance D. The object is to eliminate the disease to the extent that no new case occurs in future Ans. C (Park 18th ed., p 35, 87) Eradication means to ‘tear out by roots’. Eradication of disease implies termination of all transmission of infection by extermination of the infectious agent. It is ‘all or none phenomenon’. The word eradication is reserved to cessation of infection and disease from the whole world. It implies that disease will no longer occur in a population. Small pox is the only disease that has been eradicated. During, recent years, diseases that have been seriously Confirmed cases during one year × 1000 advanced as candidates for global eradication within the foreseeable future are diphtheria, polio, measles and Population under surveillance dracunculiasis (guinea worm). Experience gained from eradication programmes (e.g., malaria, yaws) has shown that once the morbidity of a disease reaches a very low level, a ‘residual’ infection usually persists in the population leading to a state of equilibrium between the agent, host and environmental components of disease process. In this situation, there are always hidden foci of infection, unrecognized methods of transmission, resistance of the vector or organism, all of which may again flare up when the agent-host-environment equilibrium is disturbed. 38. All of the following statements about National Malaria Control Programme are true except: A. Number of slides examined should amount to at least 10% of the population under surveillance in a year B. Annual parasite incidence is based on active and passive surveillance and cases confirmed by blood examination C. Annual blood examination rate is calculated from the number of slides examined per 100 cases of fever D. The slide positivity rate provides information on the trend of malaria transmission Ans. C (Park 18th ed., p 207) Annual parasite incidence (API) is given by the formula: = API is a sophisticated measure of malaria incidence in a community. It is based on intensive active and passive surveillance, and cases are confirmed by blood examination. Annual blood examination rate (ABER) is given by the formula: Number of slides examined = × 100 Population The WHO Expert Committee on Malaria in 1964 recommended that the monthly number of slides examined should amount to at least 1 percent of the population. In the Modified Plan of Operation, the minimum prescribed is 10 percent of the population in a year. 1998.50 Rapid Digest UPSC – Combined Medical Services Examination ABER is an index of operational efficiency. API depends upon the annual blood collection and examination rates. A sufficient number of blood slides must be systemically obtained and examined for malaria parasite to workout accurate API. Slide positivity rate and slide falciparum rate provide information on the trends of malaria transmission. 39. The international quarantine period, as approved by the Government of India is: A. 6 days B. 9 days C. 10 days D. 12 days Ans. A (Park 18th ed., p 102; WHO Manual on Health Regulations) Quarantine has been defined as ‘the limitation of freedom of movement of such well persons or domestic animals exposed to communicable disease for a period of time not longer than the longest incubation period of the disease, in such manner as to prevent effective contact with those not so exposed’. Quarantine measures are also applied by a health authority to a ship, an aircraft, a train, road vehicle, other means of transport or container, to prevent the spread of disease, reservoirs of disease or vectors of disease. According to WHO manual on health regulations and as approved by Govt. of India the only vaccination certificate required by a person entering India is of yellow fever if that person is coming from a yellow fever endemic area. 1. For entry into India: Any person, foreigner or Indian, (excluding infants below six months) arriving by air or sea without a vaccination certificate of yellow fever will be kept in quarantine isolation for a period up to 6 days if: a. He arrives in India within 6 days of departure from an infected area. b. Has come on a ship which has started from or transited at any port in a yellow fever affected country within 30 days of its arrival in India provided such ship has not been disinfected in accordance with the procedure laid down by WHO. 2. For leaving India: There is no health check requirement by Indian Government on passengers leaving India. Persons leaving for a yellow fever infected area are advised in their own interest to be in possession of valid yellow fever vaccination certificates before they leave the country. The Government of Guyana requires that all persons including diplomats travelling to that country from India to possess valid yellow fever and cholera inoculation certificates before they leave India. An administrative arrangement for the health control of sea, air and land traffic exists between the Government of India and the Government of Bangladesh. It implies that if any aircraft or ship or land traffic from a third country arrives first at any airport or port or border checkpost in either of the agreement countries and then directly (without touching any other third country enroute) reaches the second country of the agreement, all health checks will be completed in the country of first arrival and the travelers will be exempted from any further health check on arrival in the second country. Persons exempted from production of vaccination certificate: The under mentioned persons are exempted from production of yellow fever vaccination certificate: a. Infants below the age of six months. b. Crew and passengers of an aircraft transiting through an airport located in yellow fever infected area provided the Health Officer is satisfied that such persons remained within the airport premises during the period of stay. A yellow fever vaccination certificate is valid only if it conforms with the model. The validity period of international certificate of vaccination or re-vaccination against yellow fever is 10 years, beginning 10 days after vaccination. Foreign nationals residing or who have passed through the yellow fever endemic countries during the preceding six days, are granted visas only after the production of vaccination certificate of yellow fever. After checking the vaccination certificate an entry read as “Valid Yellow fever Vaccination Certificate Checked” is made in the passport of the foreigner. 40. In a clinical trial, two drugs A and B were administered to alternate patients in 100 cases of hypertension and the effect of these two drugs was studied statistically by applying chi square test. The value of chi square was 4.12 with degree of freedom equal to one against the table value of 3.84 at 5% level. Which of the following conclusions can be drawn from this study? 1. Null hypothesis is proved 2. Null hypothesis is rejected 3. There is no significant difference between the effect of two drugs 4. The probability of the effect of the two drugs being the same are less than 0.05 UPSC Paper-2 1998 1998.51 Select the correct answer using the codes given below: Codes: A. 1 and 3 B. 2 and 3 C. 2 and 4 D. 1, 3 and 4 Ans. C (Simple Biostatistics 1st ed., Indrayan and Satyanarayana p 154, 171) The null hypothesis in this trial is that the two drugs A and B are equally effective. The calculated chi-square value of 4.12 at one degree of freedom on comparison with the table value of 3.84 indicate the statistically significant difference between the drug effectiveness. This also means that the null hypothesis of equality is rejected at 5% level of significance or P < 0.05. 41. Which of the following pairs of health indicators and targets fixed for 2000 AD are correctly matched? 1. Crude birth rate (per 1000 population) – 21 2. Maternal mortality rate (per 1000 live births) – Below 2 3. Annual growth rate (%) – 1.2 Select the correct answer using the codes given below: Codes: A. 2 and 3 B. 1 and 2 C. 1 and 3 D. 1, 2 and 3 Ans. D (Park 15th ed., p 597) According to the National Health Policy 1983, specific goals to be achieved by year 2000 are: Indicator 1. Infant mortality rate Below 60 2. Perinatal mortality rate 30-35 3. Crude death rate 9.0 4. Under 5 mortality rate 10 5. Maternal mortality rate Below 2 6. Life expectancy at birth Males 64 Females 64 7. Crude birth rate 21.0 8. Net reproduction rate 1.0 9. Couple protection rate (%) 60 10. Annual growth rate 1.20 11. Family size 2.3 12. Babies with birth weight below 2500 g(%) 10 13. Immunization TT coverage for pregnant women (%) 100 DPT 100 Polio 85 BCG 85 42. Dengue virus appears to have a direct man-mosquito-man cycle in India. The mechanism of dengue virus survival in the interepidemic period is: A. Non-human reservoir B. Dormant or latent phase in man C. Transovarian transmission of the virus D. Poor housekeeping by the public Ans. C (Park 18th ed., p 199) The reservoir of dengue is both man and mosquito. The transmission cycle is ‘man-mosquito-man.’ Aedes aegypti is main vector. Once the mosquito becomes infective, it remains so for life. Transovarian transmission i.e., the infectious agent is transmitted vertically from the infected female to her progency in the vector, of dengue virus has 1998.52 Rapid Digest UPSC – Combined Medical Services Examination been demonstrated. Temperature plays an important role in the transmission of dengue virus by mosquitoes. Mosquitoes kept at 26°C fail to transmit DEN-2 virus. Hence the low incidence of DHF in certain seasons could be explained by this observation. 43. Which one of the following insecticides is commonly used for ultra low-volume fogging? A. Abate B. DDVP C. Paris green D. Malathion Ans. D (Park 18th ed., p 579, 590) The most extensively used insecticides for ULV (ultra low volume) fogging/space spraying are malathion and fenitrothion (OMS-43). Malathion has the least toxicity of all organophosphorus compounds. It is used in doses of 100-200 mg sq foot, every 3 months. As a ULV spray, it is widely used for killing adult mosquitoes to prevent or interrupt dengue haemorrhagic fever and mosquito borne encephalitis epidemics. 44. Each tablet of the iron and folic acid tablets supplied under the CSSM programme contains: Elemental iron Folic acid A. 100 mg 500 μg B. 60 mg 500 μg C. 300 mg 500 μg D. 200 mg 500 μg Ans. A (DK Taneja National Health Policies and Programme in India, 3rd ed., p 128) To make up for the extra iron requirements during pregnancy, the diet must be supplemented with iron and folic acid tablets. Under CSSM programme all pregnant woman must be given one tablet of iron and folic acid containing 100 mg of elemental iron (300 mg of ferrous sulphate) and 500 μg (0.5 mg) of folic acid daily, for at least 100 days. Women with visible signs of anaemia and Hb below 11 g% must be given 2 tablets daily. Remember of the following important points commonly asked in examination: A woman needs twice the amount of iron daily as compared to an adult man. In the 3rd trimester, a pregnant woman needs 6 times more iron than a non-pregnant woman. The following 11 (eleven) items consist of two statements, one labelled the ‘Assertion A’ and the other labelled the ‘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 to 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 45. Assertion A : Self-care is a logical necessity and appropriate strategy in the present days. Reason R : The changing disease pattern suggests a shift from acute to chronic diseases. Ans. A (Park 18th ed., p 20) A recent trend in health care is self care. It is defined as ‘those health generating activities that are undertaken by the persons themselves’. It refers to those activities individuals undertake in promoting their own health, preventing their own disease, limiting their own illness and restoring their own health. These activities are undertaken without professional assistance, although individuals are informed by technical knowledge and skills. Self care activities comprise observance of simple rules of behaviour relating to diet, sleep, exercise, weight, alcohol, smoking and drugs. Others include attention to personal hygiene, cultivation of healthful habits and lifestyle, submitting oneself to selective medical examinations and screening; accepting immunization and carrying out other specific disease prevention measures, reporting early when sick and accepting treatment, undertaking measures for the prevention of a relapse or of the spread of the disease to others, family planning. The shift in disease patterns from acute to chronic disease makes self care both a logical necessity and an appropriate strategy. By teaching patients self care (e.g., recording own blood pressure, examination of urine for sugar) the burden on the official health services would be considerably reduced. In other words, health must begin with the individual. UPSC Paper-2 1998 1998.53 46. Assertion A : Randomised control trials are useful studies. Reason R : Randomization eliminates bias. Ans. B (Simple Biostatistics, 1st ed., Indrayan and Satyanarayana, p 236) Randomization is allocation of subjects to different groups in a random manner. The objective is that unaccounted factors are almost equally distributed among groups, and there is no bias on this count. Randomized controlled trial is a trial where there is a control group (in addition to the test group) and the allocation of subjects to the control and test groups is by random method. This is considered to be the ideal methodology to evaluate efficacy of a new regimen particularly when it is double blind. 47. Assertion A : BCG can be given at birth. Reason R : Maternal cell mediated immunity is not transferred to the foetus. Ans. A (Park 18th ed., p 149, 157; OP Ghai 6th ed., p 192) According to OP Ghai “….BCG may be given any time from birth since mother’s immunity is not transferred to the foetus. Neonatal BCG is recommended mainly to use the opportunity of the infant being available.…” Man has no inherited immunity against tuberculosis. It is acquired as a result of natural infection or BCG vaccination. Both delayed hypersensitivity and acquired resistance to tuberculosis are cell mediated responses. Delayed hypersensitivity is immunologically specific but it has no relation to antibodies and could not be transferred passively by serum. Both delayed hypersensitivity and cell mediated immunity are mediated by T lymphocytes. The aim of BCG vaccination is to induce a benign, artificial primary infection which will stimulate an acquired resistance to possible subsequent infection with virulent bacilli. In countries like India where tuberculosis prevalence and risk of childhood infection is high, BCG is administered early in infancy either at birth (for institutional deliveries) or at 6 weeks of age. BCG administered early in life provides a high level of protection, particularly against the severe forms of childhood tuberculosis and tuberculous meningitis. 48. Assertion A : Presence of nitrites in water indicates recent sewage contamination. Reason R : Sewage based nitrites get oxidised to nitrates with the passage of time. Ans. A (Park 12th ed., p 368) Nitrites presence indicates pollution of recent origin. It should be zero in potable waters. However in deep well waters, nitrites may be found as a result of reduction of nitrates by ferrous salts. Therefore water containing nitrites, except in case of deep well waters, must be viewed with suspicion. The final report about the significance of nitrites is based on the other indices of pollution such as oxygen absorbed and ammonia content. Nitrates tell the chemical story of the past history of water. Their presence indicates an old contamination provided nitrites are absent. Nitrates in water should not exceed 1 mg/l. Nitrate in groundwater originates primarily from fertilizers, septic systems, and manure storage or spreading operations. Nitrate is essentially harmless. However, certain kinds of bacteria in the digestive tract reduce the nitrate into nitrite, a much more harmful substance. The nitrite then enters the blood stream, where it can restrict the blood’s ability to provide oxygen to the body, causing blueness of the skin. This potentially fatal condition, known as methemoglobinemia, is also called “blue baby syndrome” because of the increased susceptibility of infants under six months of age. 49. Assertion A : External cephalic version is contraindicated in a patient with placenta praevia. Reason R : External cephalic version can cause uterine rupture. Ans. B (William Obstetrics 21st ed., p. 531; DC Dutta Textbook of Obstetrics 6th ed., p 380) External cephalic version is contraindicated in placenta previa as placenta is low lying and interferes with version and there is a risk of placental seperation and bleeding. Complications of version are: Placenta abruption. Uterine rupture. Amniotic fluid embolism. Fetomaternal haemorrhage. Isoimmunization. Preterm labour. Fetal distress. Fetal demise. 1998.54 Rapid Digest UPSC – Combined Medical Services Examination 50. Assertion A : Following obstructed labour, the VVF may manifest 7 to 14 days after delivery. Reason R : In obstructed labour, the prolonged compression of bladder wall and vagina between the presenting part and symphysis pubis leads to ischaemic necrosis. Ans. A (Jeffcoate’s Principles of Gynaecology International ed., 2001, p 252) Prolonged obstructed labour in women with cephalopelvic disproportion or malpresentation leads to ischaemic vascular injury from compression of the soft tissues between fetal head and maternal pelvis. Ischaemic tissue necrosis leads to development of genitourinary fistula in the puerperium, usually after 7-10 days. Fistula from long and difficult labour always involves the trigone of the bladder which is nipped between the presenting part and the back of the symphysis pubis. 51. Assertion A : Combined oral contraceptive pill has a protective effect against pelvic inflammatory disease. Reason R : Combined oral contraceptive pill produces impaired endometrial development. Ans. B (Ashok Kumar Essentials of Gynaecology 1st ed., p 12, 13) Both the statements are true but the reason is not correct. OCP causes endometrial suppression, which leads to oedematous stroma with thin atrophic glands. OCP protects against PID. Thick cervical mucous provides protection by inhibiting ascending infection. This decreases tubal damage and scarring, chronic pelvic pain and infertility. OCP also provides protection against the following: 1. Endometriosis. 2. Premenstrual tension. 3. Functional ovarian cyst. 4. Ovarian CA. 5. Ectopic pregnancy. 6. Endometrial CA. 7. Benign breast disease. 8. Fibroid. 9. PCOD. 10. Rheumatoid arthritis. 11. Hirsuitism. 12. Acne. 52. Assertion A : Corticosteroids are indicated in children with acute bronchiolitis. Reason R : In acute bronchiolitis, airway obstruction is mainly inflammatory in nature. Ans. D (OP Ghai 6th ed., p 353; Nelson 16th ed., p 1417) In bronchiolitis the inflammation of the bronchiolar mucosa leads to edema, thickening, formation of mucus plugs and cellular debris. There is no role of steroids in treatment of bronchiolitis. Oxygen remains the mainstay of treatment and mainly treatment is symptomatic. 53. Assertion A : Examination of eye is important in every child with cirrhosis. Reason R : Ocular examination provides a clue to the degree of portal hypertension. Ans. C (OP Ghai 5th ed., p 267; 6th ed., p 287) Ocular examination in a child with cirrhosis is done for: Chorioretinitis: CMV, toxoplasma, rubella. Cataract: Galactosemia. Cherry red spot: Lipid storage disorders. K-F ring: Wilson disease. Ocular examination is done for ruling out above mentioned etiology for cirrhosis. 54. Assertion A : A newborn with massive meconium aspiration should always be given antibiotics. Reason R : Meconium is a good culture medium for bacterial growth. Ans. C (Nelson 17th ed., p 584) UPSC Paper-2 1998 1998.55 Meconium stained amniotic fluid is found in 5-15% of births and usually occurs in term or post-term infants. Five per cent of such infants develop meconium aspiration pneumonia; 30% of these require mechanical ventilation, and less than 10% expire. Either in utero or more often with the first breath, thick, particulate meconium is aspirated into the lungs. The resulting small airway obstruction may produce respiratory distress within the first hours, with tachypnea, retraction, grunting, and cyanosis in severely affected infants. Partial obstruction of airways may lead to pneumothorax or pneumomediastinum, or both. Meconium is not a good culture medium for bacterial growth. Chemical pneumonia, atelectasis, small airways obstruction are the main features. Patient may require ventilator support with oxygenation. Antibiotics are added to prevent bacterial infection of respiratory tract and lung parenchyma in such a condition. 55. Assertion A : Petechial haemorrhages, haematuria, melena, sub-conjunctival haemorrhages are features of scurvy. Reason R : Platelet aggregation is known to be impaired in vitamin C deficiency states. Ans. C (Nelson 17th ed., p 185) In scurvy petechial hemorrhages may occur in the skin and mucous membranes. Hematuria, melena, and orbital or subdural hemorrhages may be found. During vitamin C (ascorbic acid) deficiency, formation of collagen and of chondroitin sulfate is impaired. The tendency to hemorrhage, defective tooth dentin, and loosening of the teeth are caused by deficient collagen. Because osteoblasts no longer form their normal intercellular substance (osteoid), endochondral bone formation stops. The bony trabeculae that have been formed become brittle and fracture very easily. The periosteum becomes loose, and subperiosteal hemorrhages occur, especially at the ends of the femur and tibia. Scurvy is associated with “weakening” of the collagen matrix that supports the blood vessels and therefore is associated with easy bruising and bleeding gums and loosening of the teeth. Prothrombin time may be greatly increased. 56. Which one of the following congenital heart diseases has cyanosis without cardiomegaly and/or congestive heart failure? A. Transposition of great arteries B. Fallot’s tetralogy C. Congenital mitral regurgitation D. Congenital pulmonary stenosis Ans. B (Nelson 17th ed., p 1524, 1526; OP Ghai 6th ed., p 407) In tetralogy of Fallot (TOF) there is cyanosis without cardiomegaly and CHF. Cyanosis and cardiac enlargement indicate severe pulmonic stenosis, otherwise mild to moderate stenosis are asymptomatic. In transposition of great arteries (TGA) with intact ventricular septum, babies are cyanotic at birth. Heart size may be normal in first 2 weeks but enlarges rapidly. Diagnosis of TOF is made clinically in a cyanotic child with a normal sized heart, mild parasternal impulse, normal first heart sound and an ejection systolic murmur ending before a single second sound. Since the right ventricle is effectively decompressed by the ventricular septal defect, congestive failure never occurs in TOF. Exceptions to this rule are: Anemia. Infective endocarditis. Systemic hypertension. Unrelated myocarditis complicating TOF. Aortic or pulmonary valve regurgitation. Remember the following important points about TOF: 1. Commonest cyanotic congenital heart disease in children above the age of 2 years. 2. Tetrad of TOF: a. VSD. b. Overriding or dextroposition of aorta. c. Pulmonary stenosis. d. Right ventricular hypertrophy. 3. Severity of cyanosis is directly proportional to severity of pulmonic stenosis but the intensity of the systolic murmur is inversely related to the severity of pulmonic stenosis. 1998.56 Rapid Digest UPSC – Combined Medical Services Examination 4. Although squatting is not specific for TOF, it is the commonest congenital lesion in which squatting is present. 5. ECG shows right axis deviation with RVH. 6. Inverted T waves in right precordial leads. 7. CXR shows normal sized heart with upturned apex with oligemic lung fields. 8. ‘Coer en sabot’ appearance is due to absence of main pulmonary region. Systemic pulmonary anastomosis are: Blalock-Tausig shunt: Subclavian artery and pulmonary artery anastomosis. Pott’s shunt: Descending aorta to pulmonary artery anastomosis. Waterston’s shunt: Ascending aorta and right pulmonary artery anastomosis. 57. A 10-day old neonate is brought by her mother to the OPD with complaints of sneezing. On examination, the respiratory rate is 40/minute and conducted sounds are heard on auscultation. There is no intercostal retraction. The neonate should be treated with: A. Normal saline nasal drops B. Oral antihistamines C. Oral antibiotics D. Parenteral antibiotics Ans. A (OP Ghai 6th ed., p 352; Nelson 17th ed., p 1390) 10 day old child with RR 40/min, no intercostal retraction having sneezing and conducted sounds is not having pneumonia and can be treated by nasal saline drops to clear the nasal passage. Table: Clinical classification of pneumonia and treatment decisions. Signs and symptoms Classification Therapy Where to treat 1. Cough or cold No pneumonia Home remedies At home No fast breathing No chest indrawing or indicators of severe illness 2. Respiratory rate Pneumonia Cotrimoxazole At home RR/minute Age 60 or more < 2 months 50 or more 2-12 months 40 or more 12-60 months 3. Chest indrawing Severe pneumonia IV/IM penicillin At hospital 4. Cyanosis Very severe pneumonia IV chloramphenicol At hospital Severe chest indrawing Inability to feed 58. Which one of the following cereals is not harmful in the case of gluten sensitive enteropathy? A. Rye B. Maize C. Wheat D. Barley Ans. B (OP Ghai 6th ed., p 281; Nelson 17th ed., p 1265) In gluten sensitive enteropathy (celiac disease) strict gluten free diet is cornerstone of management. Rice and maize act as substitute of wheat. Remember the following important points about celiac disease: 1. In celiac disease there is permanent intestinal intolerance to dietary wheat gliadin and related proteins, produce lesion in genetically susceptible individual. 2. Characteristically dramatic response to gluten fee diet. 3. Immunologically mediated small intestinal enteropathy. 4. Chronic diarrhea, abdomen distension, muscle wasting, failure to thrive, anorexia and irritability. 5. Mandatory for diagnosis: Villous atrophy with hyperplasia of crypts and abnormal surface epithelium while patient is eating adequate amount of gluten. Full clinical and histological remission after withdrawal of gluten from the diet. Antiendomysial antibodies are best sensitive and specific marker. Increased risk of lymphoproliferative disease in patients on a normal gluten containing diet. UPSC Paper-2 1998 1998.57 59. A 5-month old formula fed infant has been brought with complaints of watery diarrhoea of 2 days duration and irritability of one day duration. He had been receiving WHO ORS at home. Physical examination reveals a markedly irritable child with a rather doughy skin and rapid pulse. The most likely diagnosis is: A. Meningitis B. Encephalitis C. Hyponatremic dehydration D. Hypernatremic dehydration Ans. D (Nelson 17th ed., p 248) The child is suffering from hypernatremic dehydration. Different types of dehydration may have different clinical manifestations. Patients with hypernatremic dehydration tend to have lesser signs of dehydration, even with a similar volume loss. Their skin is warm and has a doughy feel. They tend to be lethargic, but very irritable when touched, and to be hypertonic and hyperreflexic. Patients with hypotonic dehydration, because of external losses and internal fluid shifts, may present with signs of profound volume depletion and shock. Fluid therapy for hypernatremic dehydration may be difficult, because severe hyperosmolality may lead to cerebral damage with widespread cerebral hemorrhages, thrombosis, and subdural effusions. Because the sodium deficit in hypernatremic dehydration is relatively small and the ECF volume relatively well maintained, the amounts of sodium and water to be administered are lower than those in hyponatremic or isonatremic dehydration. A suitable regimen is a 5% dextrose solution containing 25 mEq/L of sodium as a combination of the bicarbonate and chloride. Frequently, seizures occur during treatment as the serum sodium is returning to normal. 60. Consider the following statements regarding post-streptococcal glomerulonephritis among children: 1. Hypertension is always present 2. Sub-clinical cases do not occur 3. Retinal changes due to hypertension are common 4. Long-term outcome is usually excellent Of these statements: A. 1, 2 and 3 are correct B. 1 and 3 are correct C. 2 and 4 are correct D. 4 alone is correct Ans. D (OP Ghai 6th ed., p 447; Nelson 17th ed., p 1740) Acute post-streptococcal GN has an excellent prognosis in childhood. Hypertension is common but not always present. Epidemiological studies have shown that asymptomatic cases are present. Retinal changes are due to severe hypertension only. Remember the following important points about post streptococcal GN: 1. Acute GN caused by group A beta-haemolytic streptococci. 2. Boys > girls, rare before 3 years. 3. Electron microscopy shows lumpy deposits on the subepithelial side of the capillary basement membrane. 4. Clinical features: Rapid onset, puffiness around eyes and pedal odema. 5. Urine colour is characteristically cola-coloured. 6. Degree of oliguria correlates with severity. 7. Urea and creatinine levels reflect degree of renal impairment. 8. ASO titre increased in more than 80% of cases. 9. Anti DNAase B is elevated in cases of streptococcal skin infection. 10. Level of serum C3 is low in 95% of case but normalizes by 5-6 weeks. 11. Persistent low C3 levels indicate other forms of GN 12. Patient with mild oliguria and BP can be managed at home. 61. An 18-month old baby presents with recurrent episodes of excessive crying followed by cyanosis, unconsciousness and occasional seizures since 9 months of age. The most likely diagnosis is: A. Epilepsy B. Anoxic spells C. Breath holding spells D. Vasovagal attack Ans. C (OP Ghai 6th ed., p 55; Nelson 17th ed., p 2010) Typical sequence of excessive crying leading to cyanosis and unconsciousness and occasional seizures since 9 months of age in 18 months old child is a case of breath holding spell (BHS). Typical sequence excludes epilepsy. In epilepsy crying does not precede the episode. 1998.58 Rapid Digest UPSC – Combined Medical Services Examination Remember the following important points about breath holding spells: 1. It occurs between 6 months and 5 years of age. 2. It has 2 types: a. Cyanotic: After a bout of excessive crying most of air is exhaled. After this narrowed vocal cord close during crying leading to breath held in expiration that in turn leads to cyanosis. If hypoxia continues for 10-15 sec convulsion occurs. b. Acyanotic/pallid: – Precipitated by fear/minor injury. – Reflex asystole due to increased response. 3. Antiepileptic therapy is not necessary. 4. Iron deficiency is associated with breath holding spells. Iron supplement for 8-12 weeks frequently abort breath holding spells. 5. Measures should be taken to avoid precipitating factor. 6. Attacks could be aborted by strong physical stimulus at the onset of the spell. The next two items are based on the following case history. Study the same carefully and attempt the two items that follow: A 2-year old male child was brought with fever of 7 days duration and convulsions of one day duration. The child weighed 9 kg and had altered sensorium. There were no other positive physical signs. 62. The most likely diagnosis is: A. Acute bacterial meningitis B. Tuberculous meningitis C. Febrile convulsions D. Enteric encephalopathy Ans. D (OP Ghai 6th ed., p 229) The child is most probably suffering from enteric encephalopathy. The main clue is history of 7 days of fever. Besides this the child has altered sensorium. Absence of other physical findings rules out meningitis in which neck rigidity is common. The main confusion is with febrile convulsion. In febrile convulsion, seizure occurs early and not after 7 days of fever and in it there is a brief phase of post ictal drowsiness and altered sensorium is absent. According to Nelson “….Febrile convulsion is associated with a rapidly rising temperature and usually develops when the core temperature reaches 39°C or greater. The seizure is typically generalized, tonic-clonic of a few seconds to 10-min duration, followed by a brief postictal period of drowsiness. Febrile seizures persisting longer than 15 min suggest an organic cause such as an infectious or toxic process and require thorough investigation. Because the seizure is no longer present by the time the child reaches the hospital, a physician’s most important responsibility is to determine the cause of the fever and to rule out meningitis”. 63. The immediate investigation(s) required in this case is/are: A. CT scan B. EEG C. CSF examination D. Blood culture and Widal test Ans. C and D The immediate investigation in this patient is CSF examination. Though clinically the patient is not a case of meningitis but still at first meningitis should be ruled out in a case of fever with seizure. Blood culture and Widal’s test are also required to establish the diagnosis because most likely meningitis will be ruled out by CSF examination. However their reports come late. Blood culture is positive in 40-60% cases of enteric fever in first week and in second week enteric fever is diagnosed by Widal test. Widal test measures antibodies against O and H antigens of S. typhi. However because of many false-positive and false-negative results, diagnosis of typhoid fever by Widal’s test alone is prone to error. 64. Consider the following statements: Cherry red spot of the macula is seen in: 1. Tay Sachs disease 2. Sandhoff disease 3. Niemann-Pick disease 4. Generalised gangliosidosis Of these statements: A. 1 alone is correct B. 2 and 4 are correct C. 1, 2, 3 and 4 are correct D. 1, 2 and 3 are correct UPSC Paper-2 1998 1998.59 Ans. C (Nelson 17th ed., p 2116; Parsons’ Diseases of the Eye 19th ed., p 334) Cherry red spot is seen in all the given conditions. Cherry red spot is seen in: Central retinal artery occlusion. Tay Sachs disease (GM2 gangliosidosis type 1). Niemann Pick disease. Gaucher’s disease. Berlin’s oedema. Sandhoff’s disease (GM2 gangliosidosis type 2). Quinine toxicity. Sialoidosis (cherry red spot myoclonus syndrome). The next two items are based on the following case history. Study the same carefully and attempt the two items that follow: A 2-day old neonate is found to be deeply jaundiced. Investigations reveal: Blood group: A Rh –ve. Hb: 10 gm%. Blood picture: Microspherocyte present. Serum bilirubin: Total 28 mg%, direct 0.9 mg%. Mother’s blood group: O Rh –ve. 65. The most likely diagnosis is: A. Rh haemolytic disease B. ABO haemolytic disease C. Congenital spherocytosis D. Crigler-Najjar syndrome Ans. C (OP Ghai 6th ed., p 308; Nelson 17th ed., p1620-1621) The baby is suffering from congenital spherocytosis. The presence of microspherocytes in a two-day-old jaundiced Rh-negative neonate indicates congenital (hereditary) spherocytosis (HS). Baby blood A negative in O negative mother excludes Rh incompatibility. In ABO incompatibility deep jaundice is never seen. Differentiating point between Crigler-Najjar syndrome and HS is presence of microspherocyte. Remember the following important points about hereditary spherocytosis: 1. Autosomal dominant mode of inheritance and may present starting from neonatal period to second decade of life. 2. Abnormality in stromal protein spectrin and ankyrin of RBC. 3. In newborn period severe hyperbilirubinemia requires phototherapy and exchange transfusion. Spleen enlargement is uncommon. 4. In just few months of life spleen is enlarged with mild jaundice. 5. In childhood chronic anemia or recurrent jaundice, gallstone, leg ulcers, hepatosplenomegaly and extramedullary haematopoiesis are seen. 6. MCH is normal, MCHC is increased, MCV is normal or increased. Osmotic fragility is increased and Coombs’ test is negative. 7. Splenectomy usually improves the disease. It should be delayed until age of 6 years. 66. The treatment of choice in the case would be: A. Packed cell transfusion B. Splenectomy C. Exchange transfusion D. Phenobarbitone Ans. C (OP Ghai 6th ed., p 308; Nelson 17th ed., p 1621) In this child due to presence of deep jaundice exchange transfusion has to be done. Later splenectomy should be performed at the age of six. See question 65 also. 67. A 2-year old child has a Mantoux test reading of 12 mm × 12 mm after 48 hours. In this case: A. Anti-TB drugs should be started even if X-ray chest and haemogram are normal B. Treatment should be started only if X-ray chest and haemogram are suggested C. One should wait till overt signs of TB appear D. No treatment is required 1998.60 Rapid Digest UPSC – Combined Medical Services Examination Ans. A (OP Ghai 5th ed., p 204) This child should be treated with anti-TB drugs even if CXR and haemogram are normal. All patients with positive tuberculin test do not need treatment. It is admissible to treat following categories of positive tuberculin reactors with INH and rifampicin for a period of 9 months in either a daily or weekly schedule: 1. Children under the age of 3 years. 2. Recent conversion of tuberculin reaction from negative to positive. 3. Radiological evidence of significant disease. 4. Evidence of tuberculous toxaemia present. 5. Child suffering from or recently recovered from measles or whooping cough. 68. Consider the following statements: Disproportionate dwarfism (short stature) is a feature of: 1. Hypopituitarism 2. Hypothyroidism 3. Achondroplasia 4. Morquio’s disease Of these statements: A. 1 and 4 are correct B. 1 and 2 are correct C. 1, 2 and 3 are correct D. 2, 3 and 4 are correct Ans. D (OP Ghai 6th ed., p 50) Table: Causes of dwarfism. Disproportionate Proportionate 1. With short limbs: 1. Normal variants: a. Achondroplasia a. Familial b. Hypochondroplasia b. Constitutional delay c. Diastrophic dysplasia 2. Prenatal causes: d. Metaphyseal chondrodysplasia a. Intrauterine infections e. Deformity due to rickets and osteogenesis imperfecta b. Intrauterine growth retardation f. Chondroectodermal dysplasia c. Genetic disorders (chromosomal and metabolic disorders) 2. With short trunk: 3. Postnatal causes: a. Spondyloepiphyseal dysplasia a. Nutritional dwarfism b. Mucopolysaccharidosis b. Endocrine disorders c. Mucolipidosis c. Psychosocial short stature (emotional deprivation) d. Caries spine d. Chronic visceral disease: Renal diseases, malabsorption, e. Hemivertebrae chronic infection, cardiopulmonary diseases, anaemias In hypothyroidism, ratio between upper and lower segment is immature. Morquio syndrome is type IV A mucopolysaccharidosis. 69. Birth weight of a child doubles at five months of age while the birth length doubles at the age of: A. 1 year B. 2 years C. 3 years D. 4 years Ans. D (OP Ghai 6th ed., p 4; Nelson 17th ed., p 31) The birth length doubles at 4 years of age. Length/height of baby: At birth: 50 cm. 3 months: 60 cm. 9 months: 70 cm. 1 year: 75 cm. 2 years: 90 cm. Indian child is 100 cm in tall at 4½ years. Thereafter child gains height about 5 cm every year until the age of 10 years. UPSC Paper-2 1998 1998.61 Weight: At birth average weight is about 3 kg. 5 months: Double of birth weight. 1 year: Triple of birth weight. 2 years: 4 times of birth weight. Newborn during first few days loses extracellular fluid equivalent to about 10% of body weight. Most full term infants regain birth weight by 10 days. Head circumferences: Birth: 35 cm. 3 months: 40 cm. 12 months: 45 cm. 2 years: 48 cm. 12 years: 52 cm. CRL is always less than head circumference during 1st year. 70. The foetal length is affected if the mother has undernutrition during the: A. First trimester B. Second trimester C. Third trimester D. Any time during the pregnancy Ans. D Maternal undernutrition anytime during pregnancy will affect fetal length. In the early part of pregnancy there is increase in cell number and in later part of pregnancy there is an increase in size of the fetal cells. Lack of maternal nutrition will affect the growth of fetus both in early and later part of pregnancy and lead to IUGR. Fetal growth is mediated by IGF-1 secreted by fetal liver. A careful look into the choices of this question will reveal that both second and third trimester are given as choices and hence it makes clear that the answer will be choice D as it is quite obvious that fetal length will increase in both second and the third trimester of pregnancy. During the 3rd trimester, weight triples and length doubles as body stores of protein, fat, iron, and calcium increase. According to Nelson “…..IUGR may be a normal fetal response to nutritional or oxygen deprivation. Therefore, the issue is not the IUGR but rather the ongoing risk of malnutrition or hypoxia. IUGR is often classified as reduced growth that is symmetric (head circumference, length, and weight equally affected) or asymmetric (with relative head growth sparing). Symmetric IUGR often has an earlier onset and is associated with diseases that seriously affect fetal cell number, such as conditions with chromosomal, genetic, malformation, teratogenic, infectious, or severe maternal hypertensive etiologies. Asymmetric IUGR is often of late onset, demonstrates preservation of Doppler waveform velocity to the carotid vessels, and is associated with poor maternal nutrition or late onset or exacerbation of maternal vascular disease (pre-eclampsia, chronic hypertension)….” 71. A term baby boy was brought with complaints of breathing difficulty. He was born normally to a primigravida. Mother’s antenatal period and labour record were normal. On examination, he was in respiratory distress. Breath sounds were not audible on the left side of the chest. Heart sounds were heard better on the right side. Abdomen was flat. There was no organomegaly. The most likely cause is: A. Congenital heart disease with dextrocardia B. Respiratory distress syndrome C. Diaphragmatic hernia D. Aspiration pneumonia Ans. C (Nelson 17th ed., p 1353) Term female baby born to primigravida with respiratory distress, absent breath sound on left side of chest, flat abdomen and heart sounds better heard on right side is typical presentation of diaphragmatic hernia. Respiratory distress syndrome usually occurs within first 6 hours and almost always in preterm babies with features of tachypnoea, retraction, grunting, cyanosis and decreased air entry. Term baby with absent breath sound on left side, heart sounds on right side and flat abdomen are not present in RDS. 72. Consider the following statements: Tracheo-oesophageal fistula in the neonatal period is characterised by: 1. Associated hydamnios in the mother 2. Associated pre-eclamptic toxaemia in the mother 3. Pneumonia in the infant 4. Excessive oro-pharyngeal secretions 1998.62 Rapid Digest UPSC – Combined Medical Services Examination Of these statements: A. 1, 2 and 3 are correct B. 1, 2 and 4 are correct C. 1, 3 and 4 are correct D. 2, 3 and 4 are correct Ans. C (OP Ghai 6th ed., p 178; Nelson 17th ed., p 1219) Tracheo-oesophagal fistula (TOF) is not associated with pre-eclampsia. Remember the following important points about tracheo-oesophageal fistula: 1. TOF is associated with polyhydramnios and single umbilical artery. 2. There is choking and cyanosis with first feed and excessive drooling of frothy saliva. 3. Overflow of milk and saliva from oesophagus and regurgitation of secretions through the fistulous tract into the lungs results in pneumonia. 4. Most common variety is upper end of the esophagus ends blindly and the lower part is connected to the trachea by a fistula. 5. Least common type is both segments open into the trachea. 6. Baby should be nursed supine 7. Gastrostomy for feeding and surgical repair should be undertaken as early as possible. 73. A 2-year old child without fever develops bone pain, vomiting and features of increased intracranial pressure following excessive medication. The drug most likely to be responsible for this is: A. Vitamin A B. Phenothiazine C. Phenytoin D. Vitamin D Ans. A (OP Ghai 6th ed., p 121; Nelson 17th ed., p 181) The child is suffering from hypervitaminosis A. Vitamin A hypervitaminosis can lead to rupture of lysosomal membrane. Acute features Chronic features Headache, vomiting, dizziness Anorexia Signs of raised intracranial tension Weight loss including bulging of anterior fontanel Painful extremity and/or papilloedema Sparse hairs Pseudotumor cerebri Hepatosplemonegaly No residual damage after stopping the vitamin Hypoplastic anemia Benign intracranial hypertension. Carotenoids do not cause toxicity except a reversible yellow colour of the skin. 74. The presence of immunoreactive trypsinogen in blood spots in a newborn is suggestive of: A. Trypsinogen deficiency B. Inborn error of tryptophan metabolism C. Cystic fibrosis D. Coeliac disease Ans. C (Nelson 17th ed., p 1442) Most newborns with cystic fibrosis can be identified by determination of immunoreactive trypsinogen in blood spots, coupled with confirmatory sweat or DNA testing. According to Nelson recent studies of neonatal screening for cystic fibrosis are driven by the hope that early treatment will dramatically alter the course of the disease. Initial screening for elevated blood levels of immunoreactive trypsinogen serves to identify a population of newborns at high risk (1 in 5) for cystic fibrosis. The difficulty of obtaining sweat tests in neonates and the severe psychologic stress created by suggesting that an infant may have cystic fibrosis both require a refinement of screening tactics. 75. In the treatment of tuberculosis, corticosteroid therapy is indicated in all of the following except: A. Progressive primary pulmonary tubrculosis B. Miliary tuberculosis C. Tubercular pericardial effusion D. Tubercular meningitis Ans. A (Harrison 16th ed., p 958, 959) There is no role of corticosteroids in progressive primary pulmonary tuberculosis. Glucocorticoid by virtue of their potent anti-inflammatory action are used in tuberculous meningitis and pericarditis. UPSC Paper-2 1998 1998.63 Role of corticosteroid in TB: 1. In seriously ill patient: a. Miliary TB. b. Severe pulmonary TB. 2. When hypersensitivity occurs due to antitubercular drugs. 3. Meningeal, renal TB or pleural effusion to reduce exudation and prevent its organization, stricture etc. 4. In AIDS patients with severe manifestations of disease. Corticosteroids are contraindicated in intestinal TB as silent perforation can occur. 76. Which of the following hormones are produced by placental synthesis? 1. Human chorionic gonadotrophin 2. Human placental lactogen 3. Prolactin 4. Estriol Select the correct answer using the codes given below: Codes: A. 1, 3 and 4 B. 1, 2, and 3 C. 1, 2 and 4 D. 2, 3 and 4 Ans. C (DC Dutta Textbook of Obstetrics 5th ed., p 36, 59; 6th ed., p 58) 1. Hormones of placenta: a. Protein hormones: – Human chorionic gonadotropin (hCG). – Human placental lactogen (HPL). – Human chorionic thyrotropin (HCT). – Human chorionic corticotropin (HCC). – Pregnancy specific β-1 glycoprotein (PSβG). – Pregnancy associated plasma protein (PAPP). b. Steroid hormones: – Oestrogens: Oestriol, oestradiol and oestrone. – Progesterone. 2. Enzymes of placenta: – Diamine oxidase. – Oxytocinase. – Phospholipase A2. Prolactin is also synthesized by decidual cells. This activity is most prominent in 2nd trimester of pregnancy. 77. Glycosuria during routine investigation of antenatal visit indicates that there is need for: A. Gestational diabetes treatment B. Dietary control C. Insulin treatment D. Glucose tolerance test screening Ans. D (DC Dutta Textbook of Obstetrics 6th ed., p 284) The various causes of glycosuria in pregnancy are: Renal glycosuria. Impaired glucose tolerance. Clinical diabetes. Lactosuria. Glycosuria during pregnancy does not always mean diabetes and hence treatment is not started without fully investigating a case. There are three steps in investigation. Step I: Confirm by testing a morning sample of urine. Test for sugar and ketone bodies. If both are present then investigate for clinical diabetes. Step II: Test for FBS and PPBS. If fasting sugar is more than 95 mg/dl and postprandial sugar is more than 120 mg/ dl then proceed to step III. Step III: Perform glucose tolerance test. If GTT confirms diabetes then go for dietary restriction with insulin therapy. 1998.64 Rapid Digest UPSC – Combined Medical Services Examination 78. Which of the following are the causes of acute pain in the abdomen in a pregnant woman? 1. Appendicitis 2. Red degeneration of fibroid 3. Acute pelvic inflammatory disease 4. Twisted ovarian tumour Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1, 2 and 4 C. 1, 3 and 4 D. 2, 3 and 4 Ans. B (DC Dutta Textbook of Obstetrics 6th ed., p 305) In DC Dutta’s Textbook of Obstetrics, acute PID is not mentioned as a cause of acute pain abdomen in pregnancy. The various causes of pain abdomen are: A. Obstetrical: 1. Early: Abortion. Disturbed ectopic pregnancy. Acute hydramnios. H. mole. 2. Late: Rupture uterus. Labour pain. Hydramnios. Abruptio placentae. Torsion of uterus. Acute fulminating toxaemia. B. Non obstetrical: 1. Medical: Pyelitis. Cystitis. 2. Surgical: Acute appendicitis. Gastric or intestinal perforation. Intestinal obstruction. Rectus sheath haematoma. Volvulus. 3. Gynaecological: Torsion of ovarian cyst. Red degeneration of fibroid. Retention of urine. 79. Which one of the following pairs is not correctly matched? A. Anaemia in pregnancy – Preterm labour B. Diabetes in pregnancy – Foetal macrosomia C. Rheumatic heart disease – Unexplained still birth D. Hypertension in pregnancy – Intrauterine growth retardation Ans. C Actually in this question all the choices are matched correctly. Severe anaemia in pregnancy may lead to preterm labour. It is mentioned as a cause of preterm labour. Foetal macrosomia is an established effect of maternal diabetes and it often leads to foetal loss. Maternal anoxia due to decompensated rheumatic heart disease may lead to IUD. This is the probable answer because the cause of stillbirth is related to decompensated RHD and it is not unexplained. Severe hypertension with pre-eclampsia is a well-known cause of IUGR. 80. Which of the following methods are employed in delivery of aftercomming head in breech presentation? 1. Burn-Marshall method 2. Forceps delivery 3. Mauriceau Smellie-Veit method 4. Pinard’s manoeuvre UPSC Paper-2 1998 1998.65 Select the correct answer using the codes given below: Codes: A. 1, 2 and 4 B. 1, 2 and 3 C. 1, 3 and 4 D. 2, 3 and 4 Ans. B (DC Dutta Textbook of Obstetrics 6th ed., p 384) Pinard’s maneuver is done to bring down the extended leg during vaginal breech delivery. Rest of the three techniques are for after coming head in breech delivery. Burns-Marshall method: The baby is allowed to hang by its weight and the assistant is asked to provide suprapubic pressure. When the neck is seen under the pubic arch the baby is grasped by the ankles and maintaining a steady traction the trunk is swung upwards and forwards forming a wide arc of a circle. When the mouth clears the vulva then trunk is depressed to deliver rest of the head. Mauriceu-Smellie-Veit technique (jaw flexion shoulder traction): In this method the baby is placed on supinated left forearm with the limbs hanging on either side. The middle and the index fingers of the left hand are placed on the malar bones on either side to maintain flexion of the head. The ring and little fingers of the pronated right hand are placed on the baby’s right shoulder, the index finger is placed on the left shoulder and the middle finger is placed on the suboccipital region. After this traction is given till the nape of neck is visible and then the foetus is carried upward and forwards towards the mother’s abdomen releasing the face, brow and lastly the trunk is depressed to release the occiput and vertex. Forceps delivery: Piper forceps is specially designed for this purpose. When the occiput lies beneath the symphysis pubis an assistant raises the legs of the child to facilitate the introduction of the blade from below. The pull of the forceps maintains an arc that follows the axis of the birth canal. 81. A 25-year old female reports in the casualty with history of amenorrhoea for two and a half months and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from os. On bimanual examination, uterus is of 10 weeks size, soft and os admits one finger. The most likely clinical diagnosis is: A. Threatened abortion B. Missed abortion C. Inevitable abortion D. Incomplete abortion Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 163) The patient is suffering from inevitable abortion. It is a type of abortion where the changes have progressed to a state from where continuation of pregnancy is not possible. The main clue in this question is dilatation of internal os of cervix (os admits one finger). In such a case dilatation and evacuation has to be done. In threatened abortion all the features are present but the os is closed. In missed abortion the foetus is dead and retained inside the uterus for a period more than four weeks. In incomplete abortion the entire products of conception are not expelled, instead a part of it is left inside the uterus. In complete abortion the entire products of conception are expelled en masse. 82. For a multiparous 40-year old woman having molar pregnancy, the treatment of choice would be: A. D & C followed by regular follow up B. Hysterectomy C. Hysterectomy and tubectomy D. VAT followed by radiation Ans. B (Shaw 13th ed., p 253) In this case the patient is multiparous (completed family) and is 40 years of age, hence the best treatment is hysterectomy to prevent choriocarcinoma. After hysterectomy the patient is put under regular follow up. During follow up the hCG is estimated and when it becomes negative in about 6 to 8 weeks time she is called 3 monthly in first year and 6 monthly in the second year. In this patient prophylactic chemotherapy with methotrexate will be required if she declines hysterectomy. If this patient had not completed her family and the age was less than forty then the best treatment would have been suction evacuation using Karman cannula. 83. In which of the following conditions would prophylactic methergin be contraindicated? 1. Suspected multiple pregnancy 2. Anaemia 3. Cardiac disease 4. Rh –ve mother 1998.66 Rapid Digest UPSC – Combined Medical Services Examination Select the correct answer using the codes given below: Codes: A. 1, 2 and 4 B. 1, 2 and 3 C. 1, 3 and 4 D. 2, 3 and 4 Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 503) Methergin is given prophylactically after delivery of anterior shoulder to prevent excessive bleeding after delivery. It is indicated to stop bleeding from atonic uterus after delivery, abortion or expulsion of hydatidiform mole. In severe anaemia methergin is indicated to stop bleeding after delivery. Contraindications to methergin: 1. Suspected plural pregnancy: The second baby is likely to be compromised due to uterine contraction if methergin is given after delivery of first baby. 2. Organic cardiac disease: It may cause sudden squeezing out of blood from uterus and volume overload leadig to CHF. 3. Severe toxaemia: There may be sudden rise of BP. 4. Rh negative mother: There is more chance of feto-maternal transfusion. 84. Consider the following statements: Moulding of the foetal skull in a normal delivery results in: 1. The reduction of the biparietal diameter 2. An increase in the sub-occipitobregmatic diameter 3. An increase in the mentro-vertical diameter Of these statements: A. 1, 2 and 3 are correct B. 1 and 2 are correct C. 2 and 3 are correct D. 1 and 3 are correct Ans. D (DC Dutta Textbook of Obstetrics 6th ed., p 86) Moulding is the alteration of the shape of the fore-coming foetal head during passage through the resistant birth passage. During normal delivery an alteration of only 4 mm in skull diameter occurs commonly. There is compression of the engaging diameter with corresponding elongation of the diameter at right angle to it. Thus in a well flexed head the engaging suboccipito-bregmatic diameter is compressed with elongation in mentovertical diameter which is at right angle to suboccipito-bregmatic diameter. During moulding the parietal bones tend to overlap the adjacent bones and in the first vertex position the right parietal bone tends to override the left one. Moulding disappears a few hours after birth. 85. Consider the following signs: 1. Increase in the fundal height 2. The uterus becoming hard and well contracted 3. Permanent lengthening of the cord Signs of placental separation in the third stage of labour would include: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. A (DC Dutta Textbook of Obstetrics 6th ed., p 133) Feature after placental separation: 1. Per abdomen: Uterus becomes globular, firm and ballotable. 2. Fundal height is slightly raised. 3. Suprapubic bulge. 4. Per vaginum: a. Slight gush of vaginal bleeding. b. Permanent lengthening of cord. Third stage concerns with separation, descent and expulsion of placenta with its membranes. 86. Prostaglandin synthetase inhibitors are not used for tocolysis in premature labour because they: A. Are ineffective in promoting uterine contraction B. Are expensive C. May cause premature closure of ductus arteriosus D. Are associated with metabolic acidosis Ans. C (DC Dutta Textbook of Obstetrics 5th ed., p 547; 6th ed., p 508, 512) UPSC Paper-2 1998 1998.67 Prostaglandin inhibitors (aspirin or indomethacin) are effective tocolytic but adverse effects such as premature closure of ductus arteriosus and congestive cardiac failure may occur. Tocolytics are drugs that inhibit uterus contractions. Various tocolytics are: – Isoxsuprine – Prostaglandin inhibitors – Ritodrine – Nifedipine – Salbutamol – Ethanol – Magnesium sulphate Under trial tocolytics: Alsiban. Nitroprusside. Potassium channel openers. 87. Consider the following findings: 1. Elongated bag of membranes 2. Sagittal suture being in one of the oblique diameters 3. Anterior fontanelle being felt near the sacroiliac joint 4. Anterior fontanelle being felt more easily Pelvic examination findings in occipito-posterior position would include: A. 1 and 3 B. 1, 2 and 3 C. 1, 2 and 4 D. 2 and 4 Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 366) Vaginal examination in occipital-posterior position: In early labour: 1. Elongated bag of membranes. 2. Sagittal suture occupies any of the oblique diameters of the pelvis. 3. Posterior fontanelle is felt near sacroiliac joint. 4. Anterior fontanelle is felt more easily. In late labour: Diagnosis is difficult because of caput formation. Unfolded pinna points towards the occiput. Occipitoposterior position is more common in anthropoid pelvis. 88. A multigravida at term with transverse lie and hand prolapse with foetal heart sound of 140/minute is best managed by: A. Internal podalic version B. Caesarean section C. External cephalic version D. Breech extraction Ans. B (DC Dutta Textbook of Obstetrics 5th ed., p 427; 6th ed., p 397) If the baby is mature and the fetal condition is good, it is preferable to do caesarean section in all cases of transverse lie with hand prolapse. There is hardly any role of external cephalic version in late labour. 89. Which of the following procedures are used to deliver extended arms in a breech vaginal delivery? 1. Classical method 2. Lovset’s manoeuvre 3. Prague’s manoeuvre Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. B (DC Dutta Textbook of Obstetrics 5th ed., p 414; 6th ed., p 387) Methods of delivery of arm (extended in breech presentation): 1. Classical. 2. Lovset. For bringing down a leg – Pinard maneuver. Prague method is reversed malar flexion and shoulder traction for delivery of head in premature baby as face to pubis. 1998.68 Rapid Digest UPSC – Combined Medical Services Examination 90. During delivery, the risk of transmission of maternal infection to the foetus is the highest in: A. Rubella B. Cytomegalovirus C. Herpes simplex virus D. Human papilloma virus Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 300) Transplacental transmission of HSV is not usual. Fetus is affected from virus shed from cervix or lower genital tract during delivery. Rubella and CMV are transmitted to fetus primarily by transplacental route. HPV does not affect fetus. 91. In normal puerperium, uterine fundus sinks below the level of symphysis pubis at the end of: A. One week B. Two weeks C. Four weeks D. Six weeks Ans. B (DC Dutta Textbook of Obstetrics 6th ed., p 146) With empty bladder and centralized uterus the fundal height is: Immediately after delivery: 13.5 cm (5½”) above the pubic symphysis. By end of 2nd week: Pelvic organ. By 6 weeks: Normal size. During first 24 hours after delivery level remains constant thereafter there is a steady decrease in height by 1.25 cm in 24 hour. Weight of uterus after 6 weeks of delivery is 60 grams. Immediately following delivery uterus measures 20 × 12 × 7.5 cm and weighs about 1000 gm. 92. Which of the following changes are observed in the first week of normal puerperium? 1. Involution of uterus 2. Increased urine output 3. Decrease in body weight Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. A (DC Dutta Textbook of Obstetrics 6th ed., p 147-148) Various physiological changes in puerperium: 1. Pulse rate: Increased few hours after normal delivery and becomes normal during the second day. 2. Temperature: – Should not be > 37.2°C (99°F) within first 24 hours. – May be slight increase by 0.5°F but comes down to normal within 12 hours. – On 3rd day slight increase in temperature due to breast engorgement, which should not last for more than 24 hours. 3. Urinary tract: – Stagnation of urine along with a devitalized bladder wall contributes to UTI. – Dilated ureters and renal pelvis return to normal size within 8 weeks – Proteinuria present in 40% cases. 4. GIT: – Increased thirst – Intestinal paraesis: Constipation. 5. Weight loss due to expulsion of uterine contents and diuresis. 6. Fluid loss: Net fluid loss of at least 2 litres during first week. Additional 1.5 litres during next 5 weeks. 7. Blood values: a. Blood volume: Decreased and by 2 weeks non pregnant level is reached. b. Cardiac output increased 60% above prelabour value. c. RBC volume and haematocrit returns to normal by end of 1st week. d. Leucocytosis: Up to 30000/mm3 may occur. UPSC Paper-2 1998 1998.69 e. Platelet count: Decreases. f. Fibrinogen: Remain high up to 2nd week of puerperium. g. ESR: Persistent high. h. Hypercoagulable state persists. 93. Which one of the following factors does not directly predispose to puerperal infection? A. Prolonged labour B. Post-dated pregnancy C. Maternal obesity D. Premature rupture of membranes Ans. B (DC Dutta Textbook of Obstetrics 6th ed., p 433) In DC Dutta Textbook of Obstetrics it is mentioned that postmaturity does not put the mother at risk. Hence we have concluded that post dated pregnancy is not a risk factor for puerperal infection. Maternal obesity seems to be a risk factor though we have not come across it directly in literature. The various risk factors for puerperal infection are: 1. Prolonged labour. 2. Premature rupture of membranes. 3. Repeated vaginal examination. 4. Instrumental delivery. 5. Toxaemia. 6. Malnutrition and anaemia. 7. Chronic debilitating illness. 8. APH and PPH. 9. Placenta previa. 10. Dehydration and ketosis. 11. Retained bits of placental tissue or membranes. 94. Which of the following are the common causes of neonatal convulsions? 1. Hypoglycemia 2. Hypocalcaemia 3. Kernicterus Select the correct answer using the codes given below: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. A (OP Ghai 6th ed., p 503) Causes of convulsions in childhood: A. Early neonatal period: – Birth asphyxia, difficult/obstructed labour. – Intraventicular haemorrhage. – Pyridoxine dependency. – Hypoglycaemia. – Hypocalcaemia. – Hypo/hypernatraemia. – Inborn error of metabolism. – Accidental injection of LA into fetal scalp during paracervical block to mother. B. Neonatal period: ↓ Ca2+, ↓ Mg2+, ↓ glucose, dyselectrolytaemia. Kernicterus. Developmental malformations: Microcephaly, porencephaly, arteriovenous fistulae, agenesis of corpus callosum Meningitis, septicemia. Intrauterine infections such as toxoplasmosis (MVDs). Tetanus neonatorum. Inborn metabolic error: PKU, galactosaemia, homocystinuria, urea cycle disorders. 95. Consider the following abnormalities: 1. Chromosomal anomalies 2. Hyperbilirubinaemia 3. Meconium aspiration syndrome 1998.70 Rapid Digest UPSC – Combined Medical Services Examination Those which are more common in the case of “small for date” newborns as compared to “preterm” newborns, would include: A. 1, 2 and 3 B. 1and 2 C. 2 and 3 D. 1 and 3 Ans. D (OP Ghai 6th ed., p 155) Table: Problems of low birth weight neonates. Preterm Small for date babies Birth asphyxia Birth asphyxia Hypothermia Hypothermia Infection Polycythaemia Hyperbilrubinaemia Meconium aspiration syndrome Necrotizing enterocolitis Hypoglycemia Feeding difficulty Infections Apnoeic spells Respiratory distress Metabolic acidosis 96. Jaundice in the newborn is physiological when: A. The infant is visibly jaundiced in the first 24 hours of birth B. The total bilirubin concentration in the serum increases by 1 mg/dl per day C. The total bilirubin concentration is above 15 mg/dl D. Jaundice persists for more than one week in a term infant Ans. D (DC Dutta Textbook of Obstetrics 6th ed., p 477; OP Ghai 6th ed., p 170, 171) Physiological jaundice usually appears on 2nd or 3rd day and disappears by the 7th to 10th day. Clinically apart from jaundice the baby is quite well. Stool and urine colour remain unaffected. Combs’ test is negative. Causes of physiological jaundice: 1. Increased RBC destruction due to shorter life span. 2. Transient decreased activity/inadequate production of enzymes from liver. 3. Reduced conversion of bilirubin to urobilinogen by intestinal bacteria. – Phase one: Lasts for 5 days in term baby and 7 days in preterm infant. There is rapid rise in serum bilirubin levels to 12-15 mg/dl. – Phase two: Decline to about 2 mg/dl which lasts for 2 weeks after which adult values are attained. In preterm phase 2 may last more than a month. No specific treatment is required. Use of phenobarbitone/phototherapy: Used for rise in bilirubin near critical level. 97. The risk of neonatal chicken pox is the maximum, if maternal infection occurs: A. During the first trimester B. During the second trimester C. Within five days of delivery D. Within six weeks of delivery Ans. C (Nelson 17th ed., p 1058) According to Nelson “.…Delivery within 1 week before or after the onset of maternal varicella frequently results in the newborn developing varicella, which may be severe. The initial infection is intrauterine, although the newborn often develops clinical chickenpox post partum. The risk to the newborn is dependent on the amount of maternal anti-VZV antibody that the fetus acquired transplacentally before birth. If there was 1-week interval between maternal chickenpox and parturition, it is likely that the newborn received sufficient transplacental antibody to VZV to ameliorate neonatal infection. Alternatively, if the interval was < 1 week, the newborn will be unlikely to have protective VZV antibody and neonatal chickenpox may be exceptionally severe….” Perinatally acquired varicella may be life threatening and should be treated with acyclovir (10 mg/kg per dose given every 8 hourly) intravenously. UPSC Paper-2 1998 1998.71 98. All of the following statements regarding the development of female genital tract are true except: A. Uterus develops from the fusion of the Mullerian ducts B. Fallopian tubes are formed from the Wolffian ducts C. Lower part of the vagina develops from the sino-vaginal bulbs D. Urogenital sinus receives the mesonephric ducts Ans. B (DC Dutta Textbook of Gynaecology 4th ed., p 33, 35; DC Dutta Textbook of Obstetrics 6th ed., p 8) Fallopian tube is developed from upper vertical part and the adjoining horizontal part of Mullerian duct. 99. After birth, the intra-abdominal portion of the umbilical vein becomes: A. Urachus B. Ligamentum venosum C. Ligamentum teres D. Lateral umbilical ligament Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 45) Umbilical vein forms ligamentium teres and ductus venosus forms the ligamentum venosum. 100. The first evidence of pubertal development in the female is the: A. Onset of menarche B. Onset of growth spurt C. Appearance of the pubic hair D. Appearance of the breast buds Ans. D (OP Ghai 6th ed., p 68; Nelson 17th ed., p 54) Appearance of breast buds is the first sign of pubertal development in girls. Sexual development in adolescent girls occurs in following order: 1. Breast development. 2. Development of pubic hairs. 3. Peak growth velocity. 4. Further development of breast and pubic hairs. 5. Menarche starts 2 years after pubic hairs start appearing. 6. Further development of breast and pubic hairs. 101. A 45-year old woman with diagnosis of atypical adenomatous hyperplasia of the endometrium should be treated by: A. Progesterone B. Danazol C. Hysteroscopic resection of endometrium D. Hysterectomy Ans. D (Shaw 13th ed., p 395) Simple endometrial hyperplasia develops carcinoma in 10 to 20% cases but atypical hyperplasia predisposes to endometrial CA in 60 to 70% cases. Hence ideal treatment is hysterectomy with or without removal of ovaries. If a younger patient does not wish for hysterectomy then she would require progesterone therapy with life long follow up. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal washing, omental biopsy and node sampling is the basic treatment if possible for all stages of endometrial CA. 102. Which of the following would a negative progersterone challenge test indicate? 1. Asherman’s syndrome 2. Metropathia haemorrhagica 3. Tuberculous endometritis 4. Premature ovarian failure Select the correct answer using the codes given below: Codes: A. 1, 2 and 4 B. 1, 2 and 3 C. 1, 3 and 4 D. 2, 3 and 4 Ans. C (Shaw 13th ed., p 283; Maturitas 1994, May; 19(1):53-7) Progesterone challenge test depends on the presence of oestrogen primed endometrium in the uterine cavity. Common causes of positive progesterone challenge test are hypothalamic dysfunction and polycystic ovarian syndrome. The test is considered positive if withdrawal bleeding occurs after administration of oral tablets of medroxyprogesterone 10 mg daily for 5 days or injection of progesterone in oil 100 mg IM. A positive test is indicator of amenorrhoea 1998.72 Rapid Digest UPSC – Combined Medical Services Examination secondary to anovulation. A negative test indicates either obstruction of uterine outflow tract or damaged endometrium or ovarian failure. Negative test will indicate Asherman’s syndrome, premature ovarian failure and tuberculous endometritis. 103. A 25-year old nulliparous woman with third degree uterine descent but no cystocele or rectocele or enetrocele is best treated with A. Fothergill’s repair B. Abdominal sling operation C. Amputation of the cervix and reconstruction D. LeFort’s operation Ans. B (Ashok Kumar Essentials of Gynaecology 1st ed., p 202) Nulliparous prolapse is usually seen in females approaching menopause. However in this patient the age is only 25 years. The best treatment for her is abdominal sling operation. The operations commonly done are: Shirodkar’s sling operation: In this operation uterosacral ligaments are fixed to the sacral promontory with nylon tape/sling of fascia lata. Purandare’s abdominal cervicopexy: In this operation strips of rectus sheath are attached to the anterior surface of cervix. Khanna’s operation: Sling is fixed to the anterior superior iliac spine. 104. A 25-year old married infertile woman having regular menstruation, fever, lower abdominal pain and dysmenorrhoea presents herself at the OPD. On examination, there are bilateral soft tender masses of 3” diameter in both fornices and uterus is of normal size. The most likely diagnosis is: A. Cystic ovaries B. Tubo-ovarian masses C. Ectopic pregnancy D. Tuberculous salpingitis Ans. B (Shaw 13th ed., p 420, 421) The patient is most likely suffering from tubo-ovarian mass. The main clue in this question is the presence of soft and tender 3” diameter mass in both the fornices. Besides this is a patient of infertility. Simple tubercular salpingitis does not present in the form of a 3” diameter mass. This is also not the presentation of ectopic pregnancy. There should be history of amenorrhoea. Patient with cystic ovaries are usually not infertile and the ovaries are usually not tender. 105. Which of the following bacteria can be sexually transmitted? 1. Chlamydia trachomatis 2. Trichomonas vaginalis 3. Group B haemolytic streptococcus 4. Neisseria gonorrhoeae Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1, 2 and 4 C. 1, 3 and 4 D. 2, 3 and 4 Ans. B (Shaw 13th ed., p 135) Chlamydia trachomatis, N. gonorrhoeae and Trichomonas vaginalis are sexually transmitted. 106. Asthenospermia means: A. Failure of the formation of sperms B. No spermatozoa in the semen C. Reduction in the motility of sperms D. Sperm count less than 20 million/ml of semen Ans. C (Shaw 13th ed., p 202) Asthenospermia: No motile sperm or diminished motility. Azoospermia: No sperm in semen. Aspermia: Means no semen. Necrospermia: Dead sperms. UPSC Paper-2 1998 1998.73 Table: Normal semen values. Total volume: 3-5 ml (average 3.5 ml). Sperm count: 60-120 million/ml. Average 100 million. 10 motile sperms per high power filed are considered normal. Motility: 80-90% (average 80%). Morphology: 80% or more normal. pH: 8. Pus cells should be absent. Normally viscous and contains fructose. 107. A 30-year old multiparous woman is found to have a 5 to 6 cm cyst in one ovary. The most appropriate line of management would be: A. Laparotomy and cystectomy B. Laparotomy and unilateral salpingo-oophorectomy C. Laparoscopic aspiration of the cyst D. Observation to see if it disappears by itself in three months Ans. A (DC Dutta Textbook of Gynaecology 4th ed., p 444; Shaw 13th ed., p 372) In young women, irrespective of parity, conservation of healthy ovary is desirable. Therefore the ovarian tumour should be enucleated (cystectomy) and if this is not possible. ovariotomy should be done. Laparotomy is necessary in every case, not only for obtaining the specimen for histology by removal of tumour but also to stage and carry out definitive debulking operation. In young woman ovarian cystectomy leaving behind the healthy ovarian tissue is the treatment of choice. Ovariotomy (or salpingo-oophorectomy) is reserved for a big tumour destroying all the ovarian tissues or gangrenous cyst in axial rotation of the pedicle. If both the ovaries are involved, ovarian cystectomy should be done at least in one ovary. In parous women around 40 years total hysterectomy with bilateral salpingo-oophorectomy may be required. Functional cysts of the ovary are predominantly follicular cyst and corpus luteum cyst and the initial treatment is conservative. 108. Which of the following are the risk factor for the development of endometrial carcinoma? 1. Prolonged use of oral contraceptives 2. Polycystic ovarian disease 3. Late menopause 4. Anovulatory DUB Select the correct answer using the codes given below: Codes: A. 1, 2 and 4 B. 1, 2 and 3 C. 1, 3 and 4 D. 2, 3 and 4 Ans. D (Shaw 13th ed., p 392) Oral contraceptive pills have a protective effect in endometrial carcinoma. Addition of progestogens to oestrogen for HRT during the last 12 to 14 days of the cycle is protective against development of endometrial cancer. Predisposing factors for CA endometrium: Unsupervised administration of oestrogen alone. Women with oestrogen dominance having endometrial hyperplasia and presenting as cases of DUB. Family history of disease due to genetic/dietetic habits. Woman taking tamoxifen Infertile women and those with fewer children and suffering from PCOD. Obesity, hypertension and diabetes are associated with 30% cases. 109. Commonest mode of death in patients of carcinoma cervix is: A. Haemorrhage B. Infection C. Obstructive uropathy D. Malnutrition Ans. C (Ashok Kumar Essentials of Gynaecology 1st ed., p 122) Renal failure (50%) is the commonest cause of death in CA cervix. Uremia develops due to ureteral obstruction after involvement of parametrium by the growth. 1998.74 Rapid Digest UPSC – Combined Medical Services Examination Remember the following important points about complications of CA cervix: 1. Haemorrhage. 2. Sepsis: Peritonitis. 3. Cachexia. 4. Pyometra. 5. VVF and rectovaginal fistula. 6. Visceral metastasis. 110. Which of the following are the targets of “Health for all” by 2000 AD in India? 1. Maternal mortality to be reduced by 50% of the current rate 2. Perinatal mortality to be reduced to 60/1000 total births 3. Contraceptive protected eligible couples to be increased to 60% Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. D (Park 15th ed., p 598) See also Q 41. Current maternal mortality rate of 4 (1993) is to be reduced below 2 i.e., reduction by 50% of the current rate. 111. Nonoxynol-9 (marketed as ‘Today’) is a/an: A. Hormonal contraceptive B. Intrauterine contraceptive C. Barrier contraceptive D. Post-coital contraceptive Ans. C (Shaw 13th ed., p 221) ‘Today’, barrier contraceptive, is a mushroom shaped polyurethane disposal sponge 2 inches in diameter and 1.25 inches thick and contains 1 g of nonoxynol-9. It acts as a mechanical barrier and prevents entry of sperm, absorbs semen and contains spermicidal solution. Failure rate is 9-30 per 100 woman years. 112. All of the following are absolute contraindications for IUCD insertion, except: A. Pelvic infection B. Pregnancy C. Undiagnosed abnormal vaginal bleeding D. Valvular heart disease Ans. D (DC Dutta Textbook of Gynaecology 4th ed., p 440; DC Dutta Textbook of Obstetrics 6th ed., p 537) Valvular heart disease is not a contraindication of IUCD insertion. Contraindications to IUCD: PID. Dysfunctional uterine bleeding. Suspected pregnancy. Prolapse uterus because of chance of ascending infection. Distortion of uterine cavity as in fibroid or congenital malformation. Difficulty in insertion and decreased efficacy of IUD in: Severe dysmenorrhoea. Suspicious cervix with abnormal cytology. Past history of ectopic pregnancy. Nulliparous. HIV (STD) positive women. Within 6 weeks following caesarean section. 113. All of the following statements regarding lost IUCD are true except: A. Pregnancy should be excluded before other evaluation is done B. Gentle probing should be done with a uterine sound C. Ultrasonography is the best method of diagnosis D. Laparotomy is required in all cases UPSC Paper-2 1998 1998.75 Ans. D (Shaw 13th ed., p 225; DC Dutta Textbook of Gynaecology 4th ed., p 441) Laboratory is not required in all cases of lost IUCD. In case of perforation, laparotomy is needed because Cu-T causes adhesions and cannot be retrieved easily through laparoscope. Causes of lost IUCD: Uterus enlarged through pregnancy. Thread has curled inside uterus. Perforation has occurred and tract is buried in myometrium. It has been expelled. Investigstions done in case of lost IUCD: 1. Pregnancy test. 2. Sounding. 3. Plain radiograph. 4. USG. 5. Hysteroscopy. 114. Which of the following are the adverse side effects of oral contraceptives? 1. Acne 2. Premenstrual tension 3. An increased risk of monilial vaginitis Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. D (Shaw 13th ed., p 229; DC Dutta Textbook of Obstetrics 6th ed., p 545) By virtue of non-ovulation OCP can relieve premenstrual tension. Acne and monilial vaginitis are side effects of OCP. Benefits of OCP: Controls fertility effectively. Useful in haemorrhoge. Polymenorrhoea. Dysmenorrhoea. Premenstral lesion. Prevent anaemia by decreasing blood loss. Decreased incidence of: – Benign breast neoplasia. – Functional ovarian cyst. – Pelvic inflammatory disease. – Ectopic pregnancy. – Protects against rheumatoid arthritis. 115. All of the following are the advantages of Depo-Provea except: A. It can be given to lactating mothers B. A 150 mg dose is effective for a period of 12 weeks C. It gives good cycle control D. It prevents ectopic pregnancy Ans. C (Shaw 13th ed., p 229) Menstrual irregularity occurs and amenorrhoea is reported in 20 to 50% at end of 1 year with use of depot medroxy- progesterone acetate. Menstrual irregularity is accepted by puerperal women as physiological. 116. The contraceptive of choice for a newly married couple wishing to postpone their first child for 2 years is: A. Safe period B. Spermicidal jelly C. Copper T D. Oral pills Ans. D (Shaw 13th ed., p 239) Out of the given choices OCP is the best and most effective method of contraception in a newly married couple. Safe period is one of the most unsafe and very difficult to practice method for newly married couple. 1998.76 Rapid Digest UPSC – Combined Medical Services Examination Spermicidal jelly alone has very little power to prevent conception. Along with a barrier method spermicidal jelly is however very effective method of contraception. Copper T is not advised in a nulliparous woman. 117. After vasectomy, aspermia will become evident in: A. 2 to 3 weeks B. 4 to 6 weeks C. 8 to 10 weeks D. 10 to 12 weeks Ans. D (Shaw 13th ed., p 234) Sperms are stored in the reproductive tract for up to 3 months and only after 10-12 weeks there is aspermia. Approximately 12 ejaculates clear the semen of all sperms. Remember the following important point about complications of vasectomy: Local pain, bleeding, haematoma formation, skin discolouration. Infection, trauma to testicular artery causing gangrene. Antibody formation and autoimmune disease. Granuloma formation. Spontaneous recanalization and failure with about 0.15/100 woman years at end of one year. Decreased libido and impotency are psychogenic. 118. During suction evacuation in MTP, the negative pressure of suction should be: A. 100 to 200 mmHg B. 200 to 300 mmHg C. 400 to 600 mmHg D. 700 to 900 mmHg Ans. C (DC Dutta Textbook of Obstetrics 6th ed., p 564) During suction evacuation in MTP the negative pressure of suction should be raised to 400-600 mmHg. Indications for suction evacuation: MTP during first trimester. Inevitable abortion. Recent incomplete abortion. Hydatidiform mole. End point of suction is denoted by: No more material is sucked out. Cupping of cannula by contracting small size uterus. Grating sensation. Appearance of bubbles in the cannula or in the transparent tubing. 119. Pregnancy should be strongly discouraged in women with: A. Mitral stenosis B. ASD C. VSD D. Eisenmenger’s syndrome Ans. D (DC Dutta Textbook of Obstetrics 6th ed., p 279) Patients suffering from Eisemmenger’s syndrome are strongly advised to avoid pregnancy. Patients with Eisenmenger’s syndrome have pulmonary hypertension with shunt (right to left) through PDA, ASD or VSD. Maternal mortality is 50% and there is high perinatal loss. Termination of pregnancy should be seriously considered. Suction evacuation is the preferred method. 120. Which of the following are the advantages of cryosurgery over electrocauterization of the cervix? 1. Less post-operative discharge 2. Less post-operative bleeding 3. Less chance of cervical stenosis Select the correct answer using the codes given below: Codes: A. 1, 2 and 3 B. 1 and 2 C. 2 and 3 D. 1 and 3 Ans. C (DC Dutta Textbook of Gynaecology 4th ed., p 539; 6th ed., p 316) Drawback of cryosurgery is excessive discharge for about 2-3 weeks. UPSC Paper-2 1998 1998.77 Advantages of cryosurgery over thermal cautery: Anaesthesia is not required. Precise destruction of tissue. There is no secondary haemorrhage. Cervical stenosis is rare. Indications of cryosurgery: Benign cervical lesion: – CIN. – Condyloma acuminata. – Leucoplakia. Condyloma acuminata/vault granulation tissue following hysterectomy. Condyloma acuminata of vulva diagnosed laparoscopically and not more than 2 cm. As palliative measure to arrest bleeding in CA cervix and vulvae.