DNBCETREVIEW2NDEDITIONERRATA

CORRECTIONSINRED
PAGE27,137 (284)PeakHCGlevelsareseenbywhatintrauterineage? (A) 810weeks (B) 1113weeks (C) 20weeks (D) 25weeks ANSWER:(A)810weeks REF:Dutta6thedp58.59,CurrentOB/GYN10thedchapter8,Williams22ndedchapter3 HUMANCHORIONICGONADOTROPHIN: hCGisaglycoproteincomposedof2subunits,alphaandbeta.Thealphasubunitiscommon toallglycoproteins,andthebetasubunitconfersuniquespecificitytothehormone. Typically,neithersubunitisactivebyitself;onlytheintactmoleculeexertshormonaleffects. Synthsizedbysyncytiotrophoblastsoftheplacenta Halflifeis3237hours,incontrasttothatofmostproteinandsteroidhormones,whichhave halflivesmeasuredinminutes. Inearlypregnancydoublingtimeis2days Canbedetectedasearlyas9daysafterthemidcycleLHpeak,whichoccurs8days afterovulationandonly1dayafterimplantation. ThehCGlevelabovewhichoneshouldidentifyanembryobytransvaginalultrasonography (TVU)isnow1,000to2,000mIU/mL,asdeterminedbythesecondinternationalstandard. Levelsprogressivelyriseandreachmaximumby810weeks/6080days/1sttrimester Fallsuntil1820weeksandremainslowuntilterm. Disappearsfromcirculationby2weeks

PAGE43 (23)Maximumfillingofventriclesisseenin? (A) Protodiastole (B) Isovolumetricrelaxation (C) Ventricularphaseofdiastole (D) Atrialcontraction ANSWER:(C)Ventricularphaseofdiastole REF:Ganongs22ndedchapter3&29,Coloratlasofphysiology6theditionbyStefan Silbernagl,AgamemnonDespopoulosPage192 Sincetheventriclesare80%fullbythefirstquarterofdiastole,thisisreferredtoasrapid ventricularfilling Valvularevents Cardiacevents ECG JVP Openingof Endofisovolumetric EndofTwave VYdescent semilunarvalves relaxationphase Closureof Endofdiastoleor LaterhalfofRwave Endofxdescent semilunarvalves beginningof isovolumetriccontraction OpeningofAV Endofisovolumetric STsegment Peakofcwave valves contraction ClosureofAV Beginningof Laterhalfoftwave valves isovolumetricrelaxation, beginningofdiastole

 Note: 1. MaximumleftventricularvolumeAttheendofIsovolumetriccontraction 2. MinimumleftventricularvolumeAttheendofisovolumetricrelaxation 3. MaximumfillingofventriclesDuringventricularphaseofdiastole PAGE51 (47)Cofactorinvolveinsulphurcontainingaminoacidmetabolismis? (A)Folicacid (B)Biotin

(C)VitaminB1 (D)VitaminB12 ANSWER:(D)VitaminB12 REF:LehningerPrinciplesofBiochemistry4theditionpage674 Methionine,cysteine,homocysteine,andtaurinearethe4commonsulfurcontainingamino acids,butonlythefirst2areincorporatedintoprotein. VitaminB12isacofactorformethioninesynthetase;ithelpstoconverthomocysteineto methionine

Note: WhilebothfolicacidandvitaminB12areinvolvedinsulphurcontainingaminoacid metabolism,vitaminB12actsascofactorandfolateactsassubstrate. Thiamineandbiotinanretwosulphurcontainingvitamins PAGE6&47 (36)AllarecorrectaboutstomachEXCEPT: (A)Pylorushasmoreacidsecretingcells (B)Lotsofmucoussecretingcellsinpylorus (C)Chiefcellssecretepepsinogen (D)Parietalcellssecreteintrinsicfactor ANSWER:(A)Pylorushasmoreacidsecretingcells REF:Graysanatomy39thedp1192

Pyloricglandsaremostlypopulatedwithmucussecretingcells,parietalcellsarefewand chiefcellsscarce Note:Thereareothercellsthatsecretemucus(asinthefoveolarcellsofthestomach),but theyarenotusuallycalled"gobletcells"becausetheydonothavethisdistinctiveshape. GASTRICGLANDS: Theycanbedividedintothreegroupsthecardiac,principal(inthebodyandfundus)and pyloricglands I. Principalglands: Locatedinbodyandfundus Inthewallsoftheglandareatleastfivedistinctcelltypes:chief,parietal, mucousneck,stemandneuroendocrine Chiefcells:sourceofpepsinogen,renninandlipase.Containzymogens, containabundantRNAandhenceintenselybasophilic Parietal(oxyntic)cells:arethesourceofgastricacidandofintrinsicfactor Neuroendocrinecells:Thesecellssynthesizeanumberofbiogenicamines andpolypeptidesimportantinthecontrolofmotilityandglandular secretion.InthestomachtheyincludecellsdesignatedasGcellssecreting gastrin,Dcells(somatostatin),andECL(enterochromaffinlike)cells (histamine). II. Pyloricglands: Pyloricglandsaremostlypopulatedwithmucussecretingcells,parietalcellsarefew andchiefcellsscarce.Incontrast,neuroendocrinecellsarenumerous,especiallyG cells,whichsecretegastrinwhenactivatedbyappropriatemechanicalstimulation (causingincreasedgastricmotilityandsecretionofgastricjuices). III. Cardiacglands: Mucussecretingcellspredominateandparietalandchiefcells,althoughpresent,are few PAGE23 (236)AllofthefollowingdrugsareusedintreatmentofHirsutismEXCEPT: Cyproteroneacetate Spironolactone Flutamide Mefipristone ANSWER:(D)Mefipristone REF:Harrisons18thedchapter49 DRUGSUSEDTOTREATHIRSUTISM: Spironolactone:Antialdosteroneantiandrogeniccompound. Cyproteroneacetate:Aprogestinthatalsohasstrongantiandrogenicaction.In additiontosingleform,itisalsoavailableinsomeformulationsofcombinedoral contraceptives. (A) (B) (C) (D)

Finasteride:5alphareductaseinhibitorthatinhibitsconversionoftestosteroneto moreactive5alphahydroxytestosterone. Metformin:Antihyperglycemicdrugusedfordiabetesmellitus.However,itisalso effectiveintreatmentofhirsutismassociatedwithinsulinresistance(e.g.polycystic ovarysyndrome) Eflornithine:Blocksputrescinethatisnecessaryforthegrowthofhairfollicles. Flutamide:Androgenreceptorantagonist.

PAGE23 (237)True about atrial myxoma is? (A) Mostcommoninleftatrium (B) Reoccursafterexcision (C) Distantmetastasesareseen (D) Morecommoninmales ANSWER:(A)Morecommoninleftatrium REF:Harrisons17thedp1495 CARDIACMYXOMA: Mostcommonprimarycardiactumors occurinallageswithoutsexpreference Mostaresporadic,somearefamilial Mostcommonsite:leftatrium Myxomasarebenignandthereforedistantmetastasesarenotseen Sporadicmyxomas Familialmyxomas Solitary Multiple Locatedinatria,mostcommonlyleft Morelikelytohavepostoprecurrence Unlikelytohavepostoprecurrence Occursinyoungerindividual PAGE53 (56)Gonorrhea can be identified by? (A) GrowthonMacConkeymedium (B) Growthat37OC (C) Bythefermentationofglucose (D) Growthin45%/60%bile ANSWER:(C)Bythefermentationofglucose REF:Anantnarayan8thep230 Thisquestionisbaseduponbiochemicalidentificationofneisseriaspecies. AllthemedicallysignificantspeciesofNeisseriaarepositiveforbothcatalaseandoxidase.

DifferentNeisseriaspeciescanbeidentifiedbythesetsofsugarsfromwhichtheywill produceacid.Forexample,N.gonorrheamakesacidfromonlyglucose;howeverN. meningitisproducesacidfrombothglucoseandmaltose. (Mnemonic:GonnococciGlucose,MeninGococciMaltose&Glucose) Otherfeatures: MeningococcuspossessantiphagocyticpolysaccharidecapsulewhileGonococcus doesnt. GonococcusisKidneyshaped/coffeebeanshapedwhilemeningococcusislens shaped Gonococcushasplasmid,meningococcusrarelyhas N.gonorrhoeaeinfectionshaveahighprevalenceandlowmortality,whereasN. meningitidisinfectionshavealowprevalenceandhighmortality. PAGE8&55 (1)AtypicalpneumoniaiscausedbyallEXCEPT: (A) Mycoplasma (B) Adenovirus (C) Chlamydia (D) Hemophilus ANSWER:(D)Hemophilus REF:JawetzsMedicalMicrobiology,24thEditionSectionVII.DiagnosticMedical Microbiology&ClinicalCorrelation>Chapter48, http://emedicine.medscape.com/article/234240overview, http://en.wikipedia.org/wiki/Communityacquired_pneumonia TYPICALCOMMUNITYACQUIREDPNEUMONIA: TypicalbacterialpathogensthatcauseCAPincludeStreptococcuspneumoniae (bothpenicillinsensitiveandresistantstrains),Hinfluenzae(bothampicillin sensitiveandresistantstrains),andMoraxellacatarrhalis(allstrainspenicillin resistant).These3pathogensaccountforapproximately85%ofCAPcases. SpneumoniaeremainsthemostcommonagentresponsibleforCAP Inselectedpatients;SaureusmaycauseCAPinindividualswithinfluenza(eg, humanseasonalinfluenzaandH1N1[swine]influenza).KpneumoniaeCAPoccurs primarilyinindividualswithchronicalcoholism.PaeruginosaisacauseofCAPin patientswithbronchiectasisorcysticfibrosis. ATYPICALCOMMUNITYACQUIREDPNEUMONIAPATHOGENS:Atypicalpneumonias canbedividedintozoonoticandNonzoonoticatypicalpathogens. ZoonoticatypicalCAPpathogensincludeChlamydophilia(Chlamydia)psittaci (psittacosis),Francisellatularensis(tularemia),andCoxiellaburnetii(Qfever). NonzoonoticatypicalCAPpathogensarecausedbyLegionellaspecies, Mycoplasmapneumonia(inyoungage),orChlamydophilia(Chlamydia) pneumonia,viruses(RSV,Adenovirus,Influenzavirus,Parainfluenzavirus,SARS) Respiratoryvirusesarethesinglemostimportantcauseofcommunityacquired pneumoniainpediatricagegroup.

Organism

ClinicalSetting

Gram Stained Smearsof Sputum Gram positive diplococci

LaboratoryStudies

Preferred Antimicrobial Therapy PenicillinG(orV, oral); fluoroquinolones orvancomycinfor highlypenicillin resistant

Streptococcus Chronic pneumoniae cardiopulmonary disease;follows upperrespiratory tractinfections Hemophilus influenzae Chronic cardiopulmonary disease;follows upperrespiratory tractinfections

Gramstainingsmearof sputum;cultureofblood, pleuralfluid;urinary antigen

Smallgram negative coccobacilli

Cultureofsputum,blood, Ampicillin(or pleuralfluid amoxicillin)if lactamase negatie; cefotaximeor ceftriaxone Cultureofsputum,blood, pleuralfluid Nafcillin

Staphylococcus Influenzaepidemic; Gram aureus nosocomial positive cocciin clumps Klebsiella pneumoniae Alcohol abuse,diabetes mellitus; nosocomial

Gram Cultureofsputum,blood, negative pleuralfluid encapsulated rods

Acephalosporin; forsevere infection,add gentamicinor tobramycin

Escherichia coli

Nosocomial;rarely, Gram community negative acquired rods

Cultureofsputum,blood, Athird pleuralfluid generation cephalosporin Cultureofsputum,blood Antipseudomonal cephalosporinor carbapenemor lactam/ lactamaeinhibitor plusan aminogycoside

Pseudomonas Nosocomial;cystic Gram aeruginosa fibrosis negative rods

Anaerobes

Aspiration, periodontitis

Mixedflora

Cultureofpleuralfluidor ofmaterilobtainedby transthoracicaspiration; bronchoscopywith proectedspecimenbrush Complementfixationtitre, coldagglutininserum titresarenothelpfulas theylacksensitivityand specificity;PCR

Clindamycin

Mycoplasma pneumoniae

Youngadults; summerandfall

PMNsand monocytes; nobacterial pathogens

Erythromycin, azithromycin,or clarithromycin; doxycycline, fluoroquinolones

Legionella species

Summerandfall; exposureto contaminated constructionsite, watersource,air conditioner; community acquiredor nosocomial

FewPMNs; nobacteria

Directimmunofluorescent examinationofsputumor tissue;immunofluorescent antibodytitre;cultureof sputumortissue; Legionellaurinaryantigen (Lpneumophilaserogroup 1only);PCR Isolationverydifficult; microimmunofluorescence withTWARantigensisthe recommendedassay

Erythromycin, azithromycin,or clarithromycin, withorwithout rifampin; fluoroquinolones

Chlamydophilia Clinicallysimilarto Nonspecific pneumoniae Mpneumoniae pneumonia,but prodromal symptomslast longer(upto2 weeks);sorethroat withhoarseness common;mild pneumoniain teenagersand youngadults Moraxella catarrhalis Preexistinglung Gram disease;elderly; negative corticosteroidor diplococci immunosuppressive therapy

Doxycycline, erythromycin, clarithromycin; fluoroquinolones

Gramstainandcultureof sputumorbronchial aspiration

Trimethoprim sulfamethoxazole oramoxicillin clavulanicacidor secondorthird generation cephalosporin Trimethoprim sulfamethoxazole, pentamidine isethionate

Pneumocystis jiroveci

PAGE28&140 (293)True about Turners syndrome is? (OMIT ALL EXCEPT) (A) Normalbreast (B) Normalgonads (C) Normalintelligence (D) Longstature ANSWER:(C)Normalintelligence REF:Harrisons18thedchapter349,Robbins7theditionpage179,

AIDS, Nothelpful CystsandtrophozoitesofP immunosuppressive indiagnosis jirovecionmethenamine therapy silverorGiemsastainsof sputumorbronchoalveolar lavagefluid;direct immunofluorescent antibodyonBALfluid

http://en.wikipedia.org/wiki/Turner_syndrome RepeatfromDecember2010,June2009(notDecember11) Turner's 45,Xor Streakgonador syndrome 45,X/46,XX immatureovary ClinicalFeatures Infancy:lymphedema,webneck,shieldchest,lowsethairline,cardiacdefectsand coarctationoftheaorta,urinarytractmalformationsandhorseshoekidney Childhood:shortstature,cubitusvalgus,shortneck,short4thmetacarpals, hypoplasticnails,micrognathia,scoliosis,otitismediaandsensorineuralhearing loss,ptosisandamblyopia,multipleneviandkeloidformation,autoimmunethyroid disease,visuospatiallearningdifficulties Adulthood:pubertalfailureandprimaryamenorrhea,hypertension,obesity, dyslipidemia,impairedglucosetoleranceandinsulinresistance,autoimmune thyroiddisease,cardiovasculardisease,aorticrootdilation,osteoporosis, inflammatoryboweldisease,chronichepaticdysfunction,increasedriskofcolon cancer,hearingloss External Internalgenitalia genitalia Hypoplastic Female female Breast Immature female

PAGE46 (33)Time duration required to generate an action potential is? (A)Threshold (B)Rheobase (C)Chronaxie (D)Refractoryperiod ANSWER:(C)Chronaxie REF:ElectrotherapySimplifiedbyNandapage276,ClinicalneurophysiologybyJasperR Daubepage864 STRENGTHDURATIONCURVE: Graphicrepresentationoftherelationshipbetweenintensity(Yaxis)andvariousdurations (Xaxis)ofthethresholdelectricstimulusofanerveormuscle Theterms"chronaxie"and"rheobase"werecoinedin1909bytheFrenchphysiologistLouis Lapicque.Rheobaseisameasureofcurrentamplitudeandchronaxieisameasureoftime (duration) Rheobaseistheintensityofelectriccurrentofinfinitedurationnecessarytoproduce minimumactionpotential. Chronaxie(orchronaxy)isthetimerequiredforanelectriccurrentdoublethestrengthof therheobasetoelicitefirstvisibleactionpotential

Eachactionpotentialisfollowedbyarefractoryperiod,whichcanbedividedintoan absoluterefractoryperiod,duringwhichitisimpossibletoevokeanotheractionpotential, andthenarelativerefractoryperiod,duringwhichastrongerthanusualstimulusisrequired

PAGE66&493 (91)&63)Asteroidbodiesareseenin? (A) Sarcoidosis (B) Syphilis (C) Chromoblastomycosis (D) Sporotrichosis ANSWER:(A)Sarcoidosis>(D)Sporotrichosis REF:Robbins7thedition,page734,8thedp738,EmergencyDermatologybyRonniWolf, BatyaB.Davidovici,JenniferL.Parish,LawrenceCharlesParispage133,InfectiousDiseases oftheSkinbyDirkM.Elstonpage50,AmericanJournalofDermatopathology:June1998 Volume20Issue3pp246249 RepeatfromJune2010 SeeAPPENDIX25forlistofFEWIMPORTANTBODIESINMEDICALSCIENCE Giantcellsmaycontainasteroidbodieswhicharetypicalofsarcoidgranulomasalthough notpathognomonic.Asteroidbodiesarestellateinclusionbodiesfoundinthe multinucleatedgiantcellsof60%ofSarcoidosiscases

Theasteroidbodiesareobservedin40%oftherarecasesofsporotrichosis.Theycanbe seeninothergranulomatousreactionshoweverextracellularstructuresmadeofspiculaeof eosinophelicmaterialinvolvedbyacentercontainingyeasts(SpendoreHoeppli phenomenon)arespecificofasteroidbodiesofsporotrichosis Extracellularasteroidbodiescomprisedofeosinophelicspiculesurroundingacentralyeat formarethoughttobedistinguishedfromasteroidbodiesofothergranulomatousreactions thataretypicallyintracellular(Rodriguez&Barrera,1997) Asteroidbodieswerefirstobservedbysplendore(1908)inBrazilinhumansporotrichosis. Thayhavebeenreportedbymanyauthorssinceandtodaytheirpresenceisgenerally acceptedaspresumptive(notdiagnostic)evidenceofsporotrichosis. Sporotrichoticasteroidbodymustnotbeconfusedwiththeintracellularasteroidbodies seeningiantcellsofgranulomatousreactions,whicharefilamentousandmyelinfiguresthat containlipid. PAGE85 (146)EndemiccretinismisseenwhenIodineuptakeislessthan? (A) 5microgram/day (B) 20microgram/day (C) 50microgram/day (D) 75microgram/day ANSWER:(B)20microgram REF:Park20theditionpage540,WHOmodelformulary2008Page499, http://www.unsystem.org/SCN/archives/npp03/ch06.htm Therearetwoschoolsofthoughtsinthismatter.Whilemostofthetextbooksareinfavour oflessthan25microgramsWHOsaysitslessthan20micrograms.Luckilybiththeoptions werenotprovided. Endemiccretinismoccursinregionswheregoitreiswidespreadandsevereandisassociated withaniodineintakeoflessthan20microgramsperday. Itisnowknownthatendemiccretinismisassociatedwithhighratesofgoitreandwith severeiodinedeficiency;forexample,withdietaryiodineintakesofaboutorbelow20mcg (micrograms)perdaycomparedwithanormaldailyintakeof80150mcg;whilegoitrealone isseenatintakelevelsbelow50mcgiodineperday. ByWHOstandards,apopulationisiodinedeficientwhenitsaverageUIE(urineiodine excretion)fallsbelow50micrograms Therecommendedintakeofiodineis:(WHO) Agegroup RDA(daily) Adults 150micrograms Pregnantandlactatingwomen 200micrograms Infants 50micrograms

Children(26years) 90micrograms Children(712years) 120micrograms PAGE96 (183)Afteraleisuretrip,apatientcomeswithgrittypainineye,andjointpain.Whatisthe mostprobablediagnosis? (A) Reiterssyndrome (B) Bachetssyndrome (C) Sarcoidosis (D) SLE ANSWER:(A)Reiterssyndrome REF:Harrisons18thedchapter325 Thisisacaseofreiterssyndromeorreactivearthritiswithaclassicaltriadofarthritis, conjunctivitis(grittyfeelingineyes)&urethritis. Importantpointsaboutreactivearthritis: Reactivearthritis(ReA)referstoacutenonpurulentarthritiscomplicatingan infectionelsewhereinthebody.Inrecentyears,thetermhasbeenusedprimarilyto refertoSeronegativearthritisfollowingentericorurogenitalinfections S.flexnerihasmostoftenbeenimplicatedincasesofReA OtherbacteriaidentifieddefinitivelyastriggersofReAincludeseveralSalmonella spp.,Yersiniaenterocolitica,Y.pseudotuberculosis,Campylobacterjejuni,and Chlamydiatrachomatis Characteristicskinlesions:circinatebalanitis,keratodermablennohemmorhagicum Aboutbechetsdiseaseremember DiagnosticCriteriaofBehchet'sDisease Recurrentoralulcerationplustwoofthefollowing: Recurrentgenitalulceration Eyelesions Skinlesions Pathergytest PAGE106 (205)InsevereMSallaretrueEXCEPT: (A) Pulsatileliver (B) Atrialfibrillation (C) OpeningsnapdelayedfromS2 (D) Lengthofmurmurisincreased ANSWER:(C)OpeningsnapdelayedfromS2 REF:Harrisons18thedchapter237,CardiovascularPathophysiologybyF.M.Kusumoto page160

 Timeintervalbetweenaorticvalveclosure(A2)andopeningsnap(OS)variesinversely withtheseverityoftheMS,thatisasthestenosisworsens,leftatrialpressureincreases andthegradientbetweenleftatrialandleftventricularpressuresincreasesforcingthe mitralvalveopensooner(shorterS2OSinterval) Thetimingoftheopeningsnapisimportantasitindicatestheseverityofthelesion.Inthe earlystagethetimingisabout0,09to0,13secaftertheaorticcomponentofS2.Asleft atrialpressureincreases,inseverecasesthisintervalmaybeasshortas0.04to0.05 seconds. SevereTRoftengivesrisetoapulsatileliveredge.NotehoweverthatbothsevereMR andMScangiverisetoTR Severityofmitralstenosis Degreeofmitralstenosis Meangradient Mitralvalvearea Mildmitralstenosis <5mmHg >1.5cm2 1.01.5cm2 <1.0cm2

Moderatemitralstenosis 510mmHg Severemitralstenosis >10mmHg

MITRALSTENOSIS: Etiology: Rheumaticfever Congenital Severemitralannularcalcification SLE,RA SignsofSeveremitralstenosis: Mitralvalvearea<1cmsquare Enddiastolicpressuregradient>10mmHg DecreasedintervalbetweenA2andOpeningsnap.

Increaseddurationofmiddiastolicmurmur Normalareaofmitralvalve:46cmsquare Leftatrialpressureisincreased Pulmonarypressureisincreased Rightventricularhypertrophyoccurs S1accentuated,normallysplitS2withaccentuatedP2 Lowpitchedrumblingmiddiastolicmurmurbestheardatapexinleftlateralposition ChestXrayfeatures: Straighteningofleftcardiacborder Prominentmainpulmonaryartery Dilationofupperlobepulmonaryveins KerleyBlines Backwarddisplacementofesophagus PAGE124 (247)TreatmentofT4N0M0stageofheadandneckcarcinomais? (A) Surgeryalone (B) Radiotherapyalone (C) Chemoradiation (D) SurgeryandRadiotherapy ANSWER:(D)SurgeryandRadiotherapy REF:Masteryofsurgery5thedvolume1page308,Schwartz'sPrinciplesofSurgery9th Chapter18DisordersoftheHeadandNecktable183,Bailey&Loves25theditionpage740, Harrisons18thedchapter88 RepeatinDecember2009 Currenttreatmentguidelinesforheadandnecksquamouscellcarcinomahavebeen publishedbytheNationalComprehensiveCancerNetwork(NCCN). SinglemodalitytherapyisadequateforT1&T2(stageIandII)lesions.Surgeryand radiotherapyareequallyeffective. ForT3andT4(withorwithoutN1,M1)surgeryistheprincipalmodalityfollowed bypostoperativeRadiotherapyforlesionssituatedprimarilyintheoralcavity.In contrast,forT3&T4oropharyngealmalignanciesareoftentreatedinitiallywith chemoradiation. Asinthequestionthespecificsiteisnotmentionedwehavetochooseintelligently MasteryofsurgerydescribessurgeryfollowedbyradiotherapyforallT3T4lesionsother thanoropharynx(lip,tongue,retromolartrigone,oralcavity,buccalmucosaandhard palate) BaileysaysThereisanincreasingmovetomanageextensivediseaseoftheoropharynx withchemoradiotherapy,providedthatpatientsaremedicallyfittotoleratethetoxicity.

 TX T0 Tis T1 T2 T3

ForT3&T4oropharyngealHarrisonsaysSuchpatientscanalsobetreatedwithcurative intent,butnotwithsurgeryorradiationtherapyalone.Combinedmodalitytherapy includingsurgery,radiationtherapy,andchemotherapyismostsuccessful.Itcanbe administeredasinductionchemotherapy(chemotherapybeforesurgeryand/or radiotherapy)orasconcomitant(simultaneous)chemotherapyandradiationtherapy.The latteriscurrentlymostcommonlyusedandbestevidencesupported HeadandneckcancerstagingAJCC: Thesystemisuniformforallheadandnecksitesexceptforthenasopharynx. AJCC/TNMStagingforHead&NeckCancer Primarytumor Unabletoassessprimarytumor Noevidenceofprimarytumor Carcinomainsitu Tumoris<2cmingreatestdimension Tumor>2cmand<4cmingreatestdimension Tumor>4cmingreatestdimension Primarytumorinvadingcorticalbone,inferioralveolarnerve,floorofmouth,orskinof face(e.g.,noseorchin) Tumorinvadesadjacentstructures(e.g.,corticalbone,intodeeptonguemusculature, maxillarysinus)orskinofface Tumorinvadesmasticatorspace,pterygoidplates,orskullbaseand/orencasesthe internalcarotidartery Unabletoassessregionallymphnodes Noevidenceofregionalmetastasis Metastasisinasingleipsilaterallymphnode,3cmorlessingreatestdimension Metastasisinsingleipsilaterallymphnode,>3cmand<6cm Metastasisinmultipleipsilaterallymphnodes,allnodes<6cm Metastasisinbilateralorcontralaterallymphnodes,allnodes<6cm Metastasisinalymphnode>6cmingreatestdimension Unabletoassessfordistantmetastases Nodistantmetastases Distantmetastases Tis T1 T2 N0 N0 N0 M0 M0 M0

T4(lip) T4a(oral) T4b(oral)

Regionallymphadenopathy NX N0 N1 N2a N2b N2c N3 MX M0 M1 Stage0 StageI StageII

Distantmetastases

TNMstaging

StageIII StageIVa StageIVb

T3 T13 T4a T4a T14a AnyT T4b

N0 N1 N0 N1 N2 N3 AnyN

M0 M0 M0 M0 M0 M0 M0

StageIVc AnyT AnyN M1 PAGE141 (296)AllaretrueaboutWilmstumorEXCEPT: (A) Presentat5yearsofage (B) Hematuriaisthepresentingsymptom (C) Presentsasabdominalmass (D) Mostcommonlymetastasizetolung ANSWER:(A)Presentsat5yearsofage REF:OPGhai7theditionpage592,Nelson17thedpage1711 WILM'STUMOR: Wilmstumor,alsodesignatednephroblastoma,isacomplexmixedembryonal neoplasmofthekidneycomposedofthreeelements:blastema,epithelia,and stroma. Theincidenceisapproximately8cases/millionchildrenyoungerthan15yrofage. Itusuallyoccursinchildrenbetween25yrofage(23yearsinOPGhai),althoughit hasalsobeenencounteredinneonates,adolescents,andadults. Mosttumorsaresporadic,butfamilialpredispositionmaybeautosomaldominant OneWilmstumorgene,WT1,locatedat11p13,hasbeenisolated.WT1encodesa zincfingertranscriptionfactorthatiscriticalfornormalkidneydevelopment. SyndromesAssociatedwithWilmsTumorandTheirClinicalandGeneticCharacteristics Syndrome ClinicalCharacteristics Chromosomeorotherabnormalities WAGR Aniridia,genitourinary Del11p13(WT1&PAX6loci) abnormalities,mentalretardation DenysDrash Earlyonsetrenalfailurewithrenal WT1mutations mesangialsclerosis,male pseudohermaphrodism,increaserisk ofWilmstumor Beckwith Organomegaly(liver,kidney, Uniparentalpaternaldisomy, Wiedemann adrenal,pancreas),macroglossia duplication11p15.5,lossof omphalocele,hemihypertrophy imprinting, mutationofp57KIP57havebeen described.Del11p15.5(WT2locus) Presentation

9 Asymptomaticabdominalmass(mostcommonpresentation,canbe bilateral) 9 Abdominalpain 9 Hematuria 9 Hypertension 9 Fever 9 Anorexia Poorprognosticfactors: 9 Unfavourablehistology 9 Hyperploidy 9 Largetumor 9 Advancedstage(II,IV) Metastasis: 9 Usuallytolung(mc)andthentoliver 9 Nonhematogenous 9 Bonemetastasisarerare StagingSystemDevelopedbytheThirdNationalWilmsTumorStudyGroup StageI Tumorlimitedtokidneyandiscompletelyexcised.Capsularsurfaceintact; notumorrupture;noresidualtumorapparentbeyondmarginsofexcision StageII Tumorextendsbeyondkidneybutiscompletelyexcised.Regionalextension oftumor;vesselinfiltration;tumorbiopsiedorlocalspillageoftumor confinedtotheflank.Noresidualtumorapparentatorbeyondmarginsof excision StageIII Residualnonhematogenoustumorconfinedtotheabdomen.Lymphnode involvementofhilus,periaorticchains,orbeyond;diffuseperitoneal contaminationbytumorspillage;peritonealimplantsoftumor;tumor extendsbeyondsurgicalmarginsmicroscopicallyormacroscopically;tumor notcompletelyremovablebecauseoflocalinfiltrationintovitalstructures StageIV DepositsbeyondstageIII(e.g.,lung,liver,bone,brain) StageV Bilateralrenalinvolvementatdiagnosis PAGE176 (130)Confoundingcanberemovedby? (A) Assignconfounderstobothcasesandcontrols (B) Stratification (C) Matching (D) Alloftheabove ANSWER(D)Alloftheabove REF:Park20theditionpage68,http://en.wikipedia.org/wiki/Confounding

Therearevariouswaystomodifyastudydesigntoactivelyexcludeorcontrolconfounding variables 1. InCasecontrolstudiesassignconfounderstobothgroups,casesandcontrols, equally. 2. InCohortstudiesmatchingisoftendonebyonlyadmittingcertainagegroupsora certainsexintothestudypopulation,andthusallcohortsarecomparableinregard tothepossibleconfoundingvariable 3. Stratification: 4. Controllingforconfoundingbymeasuringtheknownconfoundersandincluding themascovariatesinmultivariateanalyses PAGE202 (30)Mostabundantextracellularbufferis? (A)Hemoglobin (B)Plasmaproteins (C)Bicarbonate (D)Phosphate ANSWER:(C)Bicarbonate REF:Ganong22ndeditionchapter39,FluidElectrolyte&AcidBasebyJackL.Keyespage80 table51 RepeatfromJune2008 COMPARTMENTWISEBUFFERSYSTEMSARE: Compartment Majorbuffer ECF Blood Plasma Plasmaproteins RBC Hemoglobin Interstitialfluid Bicarbonate ICF Phosphate>Proteins NOTE: BicarbonateisthepredominantbufferofECFasawhole Hemoglobinisthepredominantbufferofbloodasawholebecausehemoglobinis presentinlargeamountsthehemoglobininbloodhassixtimesthebuffering capacityoftheplasmaproteins Althoughhemoglobinisintracellular(insideRBC),itisoftenconsideredECFbuffer becauseRBCisacellularcomponentofECFandbecauseofthecellularpermeability ofRBCmembrane.

PAGE211 (59)Chlamydiaescapeskillingby? (A)Inhibitphagolysosomefusion (B)Causescellmembraneperforation (C)Producesfactorsthatcamouflageit (D)Molecularmimicry ANSWER:(A)Inhibitphagolysosomefusion REF:Chlamydiapneumoniae:infectionanddiseasebyHermanFriedman,Yoshimasa Yamamoto,MauroBendinelliPage103,TextbookofbacteriologybyKennethTodartable2 (http://textbookofbacteriology.net/antiphago.html) Microorganismsinvadingtissuesarefirstandforemostexposedtophagocytes.Bacteriathat readilyattractphagocytesandthatareeasilyingestedandkilledaregenerallyunsuccessful aspathogens.Incontrast,mostbacteriathataresuccessfulaspathogensinterferetosome extentwiththeactivitiesofphagocytesorinsomewayavoidtheirattention.

Asummaryofbacterialmechanismsforinterferencewithphagocytesisgiveninthetable below. BACTERIALINTERFERENCEWITHPHAGOCYTES BACTERIUM TYPEOFINTERFERENCE MECHANISM Streptolysininduceslysosomaldischarge intocellcytoplasm

Streptococcuspyogenes Killphagocyte

Inhibitneutrophilchemotaxis Streptolysinischemotacticrepellent Resistengulfment(unlessAb MProteinonfimbriae ispresent) Avoiddetectionby phagocytes Hyaluronicacidcapsule Leukocidinlysesphagocytesandinduces lysosomaldischargeintocytoplasm ProteinAblocksFcportionofAb; polysaccharidecapsuleinsomestrains Carotenoids,catalase,superoxidedismutase detoxifytoxicoxygenradicalsproducedin phagocytes

Staphylococcusaureus Killphagocyte Inhibitopsonized phagocytosis Resistkilling

 Bacillusanthracis Streptococcus pneumoniae Klebsiellapneumoniae Pseudomonas aeruginosa Salmonellatyphi Salmonellaenterica (typhimurium)

Inhibitengulfment

Cellboundcoagulasehidesligandsfor phagocyticcontact

Killphagocytesorundermine AnthraxtoxinEF phagocyticactivity Resistengulfmentandkilling CapsularpolyDglutamate Resistengulfment(unlessAb Capsularpolysaccharide ispresent) Resistengulfment Polysaccharidecapsule Polysaccharidecapsule ExotoxinAkillsmacrophages;Cellbound leukocidin Alginateslimeandbiofilmpolymers BacteriadevelopresistancetolowpH, reactiveformsofoxygen,andhost "defensins"(cationicproteins) Listeriolysin,phospholipaseClyse phagosomemembrane Capsule Proteincapsuleoncellsurface Yopproteinsinjecteddirectlyinto neutrophils Cellwallcomponentspreventpermeation ofcells;solublesubstancesdetoxifyoftoxic oxygenradicalsandpreventacidificationof phagolysosome Mycobacterialsulfatidesmodifylysosomes

Haemophilusinfluenzae Resistengulfment Killphagocyte Resistengulfment

Resistengulfmentandkilling Vi(K)antigen(microcapsule) Survivalinsidephagocytes

Listeriamonocytogenes Escapefromphagosome

Clostridiumperfringens Inhibitphagocytechemotaxis toxin Yersiniapestis Yersiniaenterocolitica Inhibitengulfment Resistengulfmentand/or killing Killphagocytes

Mycobacteria Mycobacterium tuberculosis Legionellapneumophila

Resistkillinganddigestion

Inhibitlysosomalfusion

Inhibitphagosomelysosomal Unknown fusion Involvesoutermembraneprotein(porin)P.I PhospholipaseA Bacterialsubstancemodifiesphagosome Cellwallsubstance(LPS?) Polysaccharidecapsulematerial Oantigen(smoothstrains);Kantigen(acid polysaccharide) Kantigen

Inhibitphagolysosome Neisseriagonorrhoeae formation;possiblyreduce respiratoryburst Rickettsia Chlamydia Brucellaabortus Treponemapallidum Escherichiacoli Escapefromphagosome Inhibitlysosomalfusion Resistkilling Resistengulfment Resistengulfment Resistengulfmentand possiblykilling

 Theinflammatoryandphagocyticresponsesofthehosttoinvadingbacteriaareimmediate andnonspecific.Asecond,specificimmuneresponseissoonencounteredbyinvasive bacteria.

PATHOGENSTRATEGIESTODEFENDAGAINSTTHESPECIFICIMMUNEDEFENSES I. ImmunologicalTolerancetoaBacterialAntigen: Toleranceisapropertyofthehostinwhichthereisanimmunologicallyspecific reductionintheimmuneresponsetoagivenantigen(Ag).TolerancetoanAgcan ariseinanumberofways,butthreearepossiblyrelevanttobacterialinfections. (A) FetalexposuretoAg.Ifafetusisinfectedatcertainstagesofimmunological development,themicrobialAgmaybeseenas"self",thusinducing tolerance. (B) HighpersistentdosesofcirculatingAg.Tolerancetoabacteriumoroneof itsproductsmightarisewhenlargeamountsofbacterialantigensare circulatingintheblood.Theimmunologicalsystembecomesoverwhelmed.
(C)

Molecularmimicry.IfabacterialAgisverysimilartonormalhost "antigens",theimmuneresponsestothisAgmaybeweakgivingadegreeof tolerance.ResemblancebetweenbacterialAgandhostAgisreferredtoas molecularmimicry.Somebacterialcapsulesarecomposedof polysaccharides(hyaluronicacid,sialicacid)sosimilartohosttissue polysaccharidesthattheyarenotimmunogenic.

II. AntigenicDisguises: Somepathogenscanhidetheiruniqueantigensfromopsonizingantibodiesor complement.Bacteriamaybeabletocoatthemselveswithhostproteinssuchas fibrin,fibronectin,orevenimmunolobulinmolecules.Inthiswaytheyareableto hidetheirownantigenicsurfacecomponentsfromtheimmunologicalsystem. S.aureusproducescellboundcoagulaseandclumpingfactorthatcause fibrintoclotandtodepositonthecellsurface. ProteinAproducedbyS.aureus,andtheanalogousProteinGproduced byStreptococcuspyogenes,bindtheFcportionofimmunoglobulins,thus coatingthebacteriawithantibodiesandcancelingtheiropsonizingcapacity bythedisorientation.

 ThefibronectincoatofTreponemapallidumprovidesanimmunological disguiseforthespirochete. E.coliK1,thatcausesmeningitisinnewborns,hasacapsulecomposed predominantlyofsialicacidprovidinganantigenicdisguise,asdoesthe hyaluronicacidcapsuleofStreptococcuspyogenes. III. Immunosuppression: Somepathogens(mainlyvirusesandprotozoa,rarelybacteria)cause immunosuppressionintheirinfectedhost.Suppressedimmuneresponsesare occasionallyobservedduringchronicbacterialinfectionssuchasleprosyand tuberculosis. IV. PersistenceofaPathogenatBodilySitesInaccessibletoSpecificImmune Response: Intracellularpathogenscanevadehostimmunologicalresponsesaslongastheystay insideofinfectedcellsandtheydonotallowmicrobialAgtoformonthecell surface.ThisisseeninmacrophagesinfectedwithBrucella,ListeriaorM.leprae. V. InductionofIneffectiveAntibody: AntibodiestendtorangeintheircapacitytoreactwithAg(theabilityofspecificAb tobindtoanAgiscalledavidity).IfAbsformedagainstabacterialAgareoflow avidity,oriftheyaredirectedagainstunimportantantigenicdeterminants,theymay haveonlyweakantibacterialaction. InthecaseofNeisseriagonorrhoeaethepresenceofantibodytoanouter membraneproteincalledrmpinterfereswiththeserumbactericidalreactionandin somewaycompromisesthesurfacedefensesofthefemaleurogenitaltract. VI. AntibodiesAbsorbedbySolubleBacterialAntigens: Somebacteriacanliberateantigenicsurfacecomponentsinasolubleformintothe tissuefluids.Thesesolubleantigensareabletocombinewithand"neutralize" antibodiesbeforetheyreachthebacterialcells StreptococcuspneumoniaeandNeisseriameningitidisareknownto releasecapsularpolysaccharidesduringgrowthintissues.

 ProteinA,producedbyS.aureusmayremainboundtothestaphylococcal cellsurfaceoritmaybereleasedinasolubleform.ProteinAwillbindtothe FcregionofIgG. VII. LocalInterferencewithAntibodyActivity: Somepathogensproduceenzymesthatdestroyantibodies. Neisseriagonorrhoeae,N.meningitidis,Haemophilus influenzae,StreptococcuspneumoniaeandStreptococcusmutans,whichcan growonthesurfacesofthebody,produceIgAproteasesthatinactivate secretoryIgAbycleavingthemoleculeatthehingeregion,detachingtheFc regionoftheimmunoglobulin.

SolubleformsofProteinAproducedS.aureusagglutinateimmunoglobulin moleculesandpartiallyinactivateIgG.

VIII. AntigenicVariation Onewaybacteriacantrickforcesoftheimmunologicalresponseistoperiodically changeantigens,i.e.,toundergoantigenicvariation. Neisseriagonorrhoeaecanchangefimbrialantigensduringthecourseofan infection. The"relapses"ofrelapsingfevercausedbythespirochete,Borrelia recurrentis,arearesultofantigenicvariationbytheorganism. PAGE212 (62)Interleukinresponsibleforpyrexiais? (A) IL1 (B) IL6 (C) INFgamma (D) IFNalpha ANSWER:(A)IL1 REF:Harrisons17thedchapter308,OxfordJournalsMedicineClinicalInfectiousDiseases Volume31,IssueSupplement5Pp.S178S184 SeeAPPENDIX19forlistofCytokinesandtherephysiologicalrole

 IL1isthemostpotentendogenouspyrogen(EP) Intheclassicalmodelofpathogenesis,inductionoffeverismediatedbythereleaseof pyrogeniccytokinessuchastumornecrosisfactor(TNF),interleukin(IL)1,IL6.GiventhatIL 6expressionisunderthecontrolofTNFandIL1,ithasbeenproposedthatIL6isa downstreammediatoroffeverfromIL1andTNF.

ENDOGENPOUSPYROGENS(EP) Cytokine EPactivity Comment IL1 +++ MostpotentEPinhumans,bothIL1andIL1areEP TNF ++ Possibleroleforbothsoluble&membraneboundform IL6 ++ IL6actsdistsallyofTNFandIL1incytokinecascade INF +or++ INF>INF>INF PAGE346347 (1) Whichisnotassociatedwithcommunityacquiredpneumonia? (A) Legionella (B) Klebsiella (C) Chlamydia (D) Pneumococcus ANSWER:(B)Klebsiella REF:JawetzsMedicalMicrobiology,24thEditionSectionVII.DiagnosticMedical Microbiology&ClinicalCorrelation>Chapter48, http://emedicine.medscape.com/article/234240overview, http://en.wikipedia.org/wiki/Communityacquired_pneumonia TYPICALCOMMUNITYACQUIREDPNEUMONIA: TypicalbacterialpathogensthatcauseCAPincludeStreptococcuspneumoniae (bothpenicillinsensitiveandresistantstrains),Hinfluenzae(bothampicillin sensitiveandresistantstrains),andMoraxellacatarrhalis(allstrainspenicillin resistant).These3pathogensaccountforapproximately85%ofCAPcases. SpneumoniaeremainsthemostcommonagentresponsibleforCAP Inselectedpatients;SaureusmaycauseCAPinindividualswithinfluenza(eg, humanseasonalinfluenzaandH1N1[swine]influenza).KpneumoniaeCAPoccurs primarilyinindividualswithchronicalcoholism.PaeruginosaisacauseofCAPin patientswithbronchiectasisorcysticfibrosis. ATYPICALCOMMUNITYACQUIREDPNEUMONIAPATHOGENS:Atypicalpneumonias canbedividedintozoonoticandNonzoonoticatypicalpathogens.

 Organism

ZoonoticatypicalCAPpathogensincludeChlamydophilia(Chlamydia)psittaci (psittacosis),Francisellatularensis(tularemia),andCoxiellaburnetii(Qfever). NonzoonoticatypicalCAPpathogensarecausedbyLegionellaspecies, Mycoplasmapneumonia(inyoungage),orChlamydophilia(Chlamydia) pneumonia,viruses(RSV,Adenovirus,Influenzavirus,Parainfluenzavirus,SARS) Respiratoryvirusesarethesinglemostimportantcauseofcommunityacquired pneumoniainpediatricagegroup. ClinicalSetting Gram Stained Smearsof Sputum Gram positive diplococci LaboratoryStudies Preferred Antimicrobial Therapy PenicillinG(orV, oral); fluoroquinolones orvancomycinfor highlypenicillin resistant

Streptococcus Chronic pneumoniae cardiopulmonary disease;follows upperrespiratory tractinfections Hemophilus influenzae Chronic cardiopulmonary disease;follows upperrespiratory tractinfections

Gramstainingsmearof sputum;cultureofblood, pleuralfluid;urinary antigen

Smallgram negative coccobacilli

Cultureofsputum,blood, Ampicillin(or pleuralfluid amoxicillin)if lactamase negatie; cefotaximeor ceftriaxone Nafcillin Acephalosporin; forsevere infection,add gentamicinor tobramycin

Staphylococcus Influenzaepidemic; Gram Cultureofsputum,blood, aureus nosocomial positivecocci pleuralfluid inclumps Klebsiella pneumoniae Alcohol abuse,diabetes mellitus; nosocomial Gram Cultureofsputum,blood, negative pleuralfluid encapsulated rods

Escherichia coli

Nosocomial;rarely, Gram community negative acquired rods Gram negative rods

Cultureofsputum,blood, Athird pleuralfluid generation cephalosporin Cultureofsputum,blood Antipseudomonal cephalosporinor carbapenemor lactam/ lactamaeinhibitor plusan aminogycoside

Pseudomonas Nosocomial;cystic aeruginosa fibrosis

Anaerobes

Aspiration, periodontitis

Mixedflora

Cultureofpleuralfluidor Clindamycin ofmaterilobtainedby transthoracicaspiration; bronchoscopywith proectedspecimenbrush

Mycoplasma pneumoniae

Youngadults; summerandfall

PMNsand monocytes; nobacterial pathogens

Complementfixationtitre, coldagglutininserum titresarenothelpfulas theylacksensitivityand specificity;PCR Directimmunofluorescent examinationofsputumor tissue;immunofluorescent antibodytitre;cultureof sputumortissue; Legionellaurinaryantigen (Lpneumophilaserogroup 1only);PCR Isolationverydifficult; microimmunofluorescence withTWARantigensisthe recommendedassay

Erythromycin, azithromycin,or clarithromycin; doxycycline, fluoroquinolones Erythromycin, azithromycin,or clarithromycin, withorwithout rifampin; fluoroquinolones

Legionella species

Summerandfall; exposureto contaminated constructionsite, watersource,air conditioner; community acquiredor nosocomial

FewPMNs; nobacteria

Chlamydophilia Clinicallysimilarto Nonspecific pneumoniae Mpneumoniae pneumonia,but prodromal symptomslast longer(upto2 weeks);sorethroat withhoarseness common;mild pneumoniain teenagersand youngadults Moraxella catarrhalis Preexistinglung Gram disease;elderly; negative corticosteroidor diplococci immunosuppressive therapy

Doxycycline, erythromycin, clarithromycin; fluoroquinolones

Gramstainandcultureof Trimethoprim sputumorbronchial sulfamethoxazole aspiration oramoxicillin clavulanicacidor secondorthird generation cephalosporin Trimethoprim sulfamethoxazole, pentamidine isethionate

Pneumocystis jiroveci

PAGE374 (133)AcuteGoutyarthritisisseenearlyintreatmentfollowing? (A) Probenecid (B) Allopurinol

AIDS, Nothelpful Cystsandtrophozoitesof immunosuppressive indiagnosis Pjirovecionmethenamine therapy silverorGiemsastainsof sputumor bronchoalveolarlavage fluid;direct immunofluorescent antibodyonBALfluid

(C) Colchicine (D) Rasburicase ANSWER:(B)Allopurinol>(A)Probenecid REF:GoodmanGillmanmanualofpharmacologyandtherapeutics2008editionpage458, Katzung9theditionpage599,Lippincottpharmacology6theditionpage443,Gout:Diagnosis andManagementofGoutyArthritisandHyperuricemiabyRobertTerkeltaub,M.D.,N. LawrenceEdwards,M.D.2ndedpage189 Althoughthetreatmentofthehyperuricemiaofgoutdependsuponloweringblooduricacid levels,mostphysicianscautionagainstemployingdrugssuchasallopurinol,probenecid,or sulfinpyrazoneduringanacuteattack,sincethetherapyitself,atleastduringtheinitial stages,mayexacerbatethecondition. Theincidenceofacuteattacksofgoutyarthritismayincreaseduringtheearlymonthsof allopurinoltherapyasaconsequenceofmobilizationoftissuestoresofuricacid.Co administrationofcolchicinehelpssuppresssuchacuteattacks.Afterreductionofexcess tissuestoresofuricacid,theincidenceofacuteattacksdecreasesandcolchicinecanbe discontinued ConcomitantcolchicineorNSAIDsareindicatedearlyinthecourseoftherapytoavoid precipitatinganattackofgout,whichmayoccurinupto20%ofgoutypatientstreatedwith probenecidalone Nowifwereadthefollowingtextitwillbecomeveryclearthatthepercentageofacute flarewithallopurinolevenwhenusedalongwithcolchicine(44.4%)ishigherthan percentageofacuteflarewithprobenecidevenwhenusedalone(20%). InaRCTofgoutpatientsinitiatedwithallopurinol,thepercentageofflareswaslowerfor canakinumab(monoclonalantibodytoIL1)groups(25mg27.3%,15mg16.7%,100mg 14.8%,200mg18.5%,300mg15.1%)thanforthecolchicinegroup(44.4%) PAGE401 (209)Hornertrantasspotisseenin? (A) Trachoma (B) PhlectenularKeratoconjunctivitis (C) VernalKeratoconjunctivitis (D) GiantPapillaryconjunctivitis ANSWER:(C)VernalKeratoconjunctivitis REF:Khurana4thedp451,Yanoff&Duckerophthalmology2ndeditionpage407 AcharacteristicmanifestationoflimbalvernalconjunctivitisisthepresenceofHorner Trantasdots,whicharewhite,chalklikedotscomposedofeosinophilsandepithelialdebris.

PAGE407 (229)Anathletepresentedwithredcolouredurineafter2daysofhistoryofsevereexertion.The mostprobablecauseis? (A)Hemoglobinuria (B)Hemosiderinuria (C)Hematuria (D)Myoglobinuria ANSWER:(D)Myoglobinuria REF:Harrison'sInternalMedicine17theditionchapter382,Physiologyandpathologyoftheurineby johndixonp49,Wintrobe'sClinicalHematology,Volume12thedpage1031 Redcolorurineinanathletemaybeduetohemoglobinormyoglobin.Henoglobinuria developsimmediatelyafterthesternousexerciseandresolvesinhourswhilemyoglobinurea developsafter2448hours. Ahemepositivedipsticktestinlongdistancerunnersisoftenduetomyoglobinuria,or occasionallytohemoglobinuria(Marchhemoglobinuria),ratherthanhematuria (http://www.nephrologyrounds.org/crus/nephus_0504.pdf;NephrologyRoundsMay2004 Volume2Issue5) Marchhemoglobinuria: Marchhemoglobinuriaisanunusualhemolyticdisordercharacterizedbyhemoglobinuria, increasedplasmahemoglobin,anddecreasedplasmahaptoglobininsusceptibleindividuals afterstrenuousexercisethatinvolvesforcefulcontactofthebodywithahardsurface. Hemoglobinuriaisprecipitatedbyprolongedmarchesorcompetitiverunning,butthe syndromehasalsobeennotedincongadrumplayersandpeopleparticipatinginkarate exercises. Passageofredordarkurineafterphysicalexertionisoftentheonlycomplaint.Occasionally, symptomsincludenausea;vagueabdominal,back,orthighpain;andaburningfeelinginthe solesofthefeet. Hemoglobinuriacharacteristicallyoccursimmediatelyafterexerciseandlastsforonlyafew hours.Marchhemoglobinuriamostcommonlyaffectsathletesatthebeginningofarunning careeroronresumptionofroadtraining Myoglobinuria: Myoglobinuriamaymimicthepresenceofhematuria.Myoglobinmayappearintheurine ofathletessecondarytothebreakdownofmusclefibers.Myoglobinuriaindicatesthe breakdownofmusclefibersduringexcessiveexercise;itusuallyappears2448hoursafter exercise. Urinedipstickcannotdifferentiatebetweenmyoglobinandhemoglobin. Hematuria Hemoglobinuria Myoglobinuria

Mechanism RBCslyseoncontactwith thereagentpad,causinga

FreeHbfilteredintourine FreeMbfilteredintourine asaresultof asaresultof

positivereaction(speckled patternmayresultiflow grade) Clinical Bleedingintourinaryspace (canoccuratanylevelof theurinaryorreproductive tract).Commonlydueto inflammation,trauma, neoplasia,hemostatic disorders.

hemoglobinemia(usually myoglobinemia(not detectableasredplasma) visuallydetectablein plasma). Intravascularhemolysisof anycause(immune mediated,toxic, mechanical,infectious, etc). Myocyteinjuryallowing releaseofmyoglobin whichreaches bloodstreamandisreadily filteredattheglomeruli.

Urine RBCwillbepresentinurine Redsupernatant,NoRBC examination sedimentexamination inurinesediment

Redsupernatant,NoRBC inurinesediment

PAGE426 (283)Investigationofchoiceinpostmenopausalbleedingis? (A) Fractionalcurettage (B) D&C (C) Colposcopyguidedendometrialbiopsy (D) PAPsmear ANSWER:(A)Fractionalcurettage REF:Novaksgynecology13theditionpage453,Dutta4thedpage331,TeLinde9thedpage 1379 Postmenopausalbleedingmostcommonlyoccursduetoendometrialatrophybutcanalso occursduetoendometrialcancerandcervicalcancer. Acaseofpostmenopausalbleedingisconsideredtobeduetoendometrialcarcinoma unlessprovedotherwise Howeverinacaseofpostmenopausalbleedingrulingoutbothendometrialandcervical cancerisalwaysapriorityandsinceinfractionalcurettagesamplesofbothendometrialand cervicaltissueistaken,itistheinvestigationofchoice.Iffractionalcurettageisnot performedthenendocervicalcurettage(ECC)shouldbeperformedinadditiontoevaluate endocervix. CAUSESOFPOSTMENOPAUSALBLEEDING Cause Percentage Exogenousestrogen 30 Atrophicendometritis/vaginitis 30 Endometrialcancer 15 Endometrialorcervicalpolyp 10 Endometrialhyperplasia 5 Miscellaneous(cervicalcancer,uterinesarcoma,trauma) 10

 CAUSESOFPOSTMENOPAUSALUTERINEBLEEDING Cause Percentage Endometrialatrophy 6080 Exogenousestrogen(HRT) 1525 Endometrialcancer 10 Endometrialpolyps 212 Endometrialhyperplasia 510 Fractionalcurettage: Theendocervicalcanaliscurettedbeforecervicaldilatationandthetissueisplacedina specificallylabeledcontainer.Theuterusisthensounded,cervixisdilatedandthe endometriumiscuretted.Theendometrialtissueisplacedinseparatecontainer. NOTE: TVShasagoodsensitivityandcouldberecommendedasthefirststepinthe investigationofpostmenopausalbleeding Officeendometrialaspirationbiopsyistheacceptedfirststepinevaluatingapatient withabnormaluterinebleedingorsuspectedendometrialpathology PAGE428,757 (293)&(249)AllaretheeffectsofgestationaldiabetesonfetusEXCEPT: (A) Macrosomia (B) Hypoglycemia (C) Congenitalmalformations (D) Increasedperinatalmortality ANSWERS:(C)Congenitalmalformations REF:CurrentDiagnosis&TreatmentObstetrics&Gynecology,10theditionchapter18, Willians22ndeditionTable522&528,http://en.wikipedia.org/wiki/Gestational_diabetes Diabetesisthemostcommonmedicalcomplicationofpregnancy. Gestationaldiabetesmellitusisatypeofdiabetesmellitus.Gestationaldiabetesisdefined ascarbohydrateintoleranceofvariableseveritywithonsetorfirstrecognitionduring pregnancy.Thisdefinitionapplieswhetherornotinsulinisusedfortreatment.Undoubtedly, somewomenwithgestationaldiabeteshavepreviouslyunrecognizedovertdiabetes CLASSIFICATIONOFDIABETESCOMPLICATINGPREGNANCY: Class Onset A1 A2 FastingPlasmaGlucose 2hourPostprandialGlucose Therapy <120mg/dL >120mg/dL VascularDisease None Diet Insulin Therapy Insulin Gestational <105mg/dL Gestational >105mg/dL

Class AgeofOnset(yr) Duration(yr) B Over20 <10

C D F R H

10to19 Before10 Any Any Any

10to19 >20 Any Any Any

None Benignretinopathy Nephropathy Proliferativeretinopathy Heart

a

Insulin Insulin Insulin Insulin Insulin

WomeninclassesBtoH,correspondingtotheWhiteclassification(1978),haveovertdiabetes antedatingpregnancy. MATERNALANDFETALEFFECTSOFGDM: Therehasbeenanimportantshiftinfocusconcerningadversefetalconsequencesof gestationaldiabetes.Importantly,unlikeinwomenwithovertdiabetes,fetalanomaliesare notincreased(Sheffieldandcolleagues,2002).Similarly,whereaspregnanciesinwomen withovertdiabetesareatgreaterriskforfetaldeath,thisdangerisnotapparentforthose whohaveonlypostprandialhyperglycemia(namely,classA1gestationaldiabetes)(Lucasand coworkers,1993;Sheffieldandcolleagues,2002). I. Fetaleffects 1. Fetaldemise(Increasedperinatalmortality) 2. Macrosomia 3. Increasedriskoflowbloodglucose(hypoglycemia),jaundice,highredblood cellmass(polycythemia)andlowbloodcalcium(hypocalcemia)and magnesium(hypomagnesemia) II. Maternaleffects 1. Increasedfrequencyofhypertension 2. Increasedfrequencyofcesareandelivery 3. Riskforcardiovascularcomplicationsassociatedwithabnormalserumlipids, hypertension,andabdominalobesitythemetabolicsyndrome MATERNAL&FETALEFFECTSOFOVERTDIABETES: I. Fetaleffects 1. Firsttrimesterabortion 2. Pretermdelivery 3. Congenitalmalformations 4. Hydramnios 5. Macrosomia 6. Fetaldemise II. Neonataleffects 1. Respiratorydistress 2. Hypoglycemia 3. Hypocalcemia 4. Hyperbilirubinemia 5. Cardiachypertrophy 6. LowriskofdevelopingType1diabetes III. Maternaleffects 1. 10foldincreaseinmaternaldeath 2. Ketoacidosis,hypertension,preeclampsia,andpyelonephritis 3. Withthepossibleexceptionofdiabeticretinopathy,however,thelongterm courseofdiabetesisnotaffectedbypregnancy.

CONGENITALMALFORMATIONSININFANTSOFWOMENWITHOVERTDIABETES Anomaly Caudalregression Situsinversus Anencephaly Heartanomalies Atrialseptaldefects Ventricularseptaldefects Transpositionofthegreatvessels Coarctationoftheaorta TetralogyofFallot Truncusarteriosus Dextrocardia Cardiomegaly RatiosofIncidencea 252 84 3 4

Spinabifida,hydrocephaly,orothercentralnervoussystemdefect 2

Anal/rectalatresia Renalanomalies Agenesis Cystickidney a Duplexureter

3 5 4 4 23

Ratioofincidenceisincomparisionwiththegeneralpopulation. Note: Chromosomalaberrationsarenotseenindiabetesmellituscomplicatingpregnancy butcongenitalmalformationsareseen Bothchromosomalaberrationsandcongenitalmalformationsarenotseenin gestationaldiabetes

PAGE440 (323)AllareseeninPTSD;posttraumaticstressdisorderEXCEPT: (A) Emotionalnumbing (B) Hallucination (C) Hyperarousal (D) Vividdreams ANSWER:(B)Hallucination REF:Kaplan&Sadock'sSynopsisofPsychiatry:10thEdition,page615,PosttraumaticStress DisorderinLitigation:GuidelinesforForensicAssessmentbyRobertI.Simonpage48, PsychiatryataGlancebyCorneliusKatona,ClaudiaCooper,MaryRobertsonpage27 ThecharacteristicfeaturesofPTSDinvolve: 1. Persistentintrusivethinkingorreexperiencing.Blank(1985)hasidentifiedfour typesofintrusiverecallinPTSD I. Vividdreamsandnightmaresoftraumaticevents

II. III. IV.

Remainingundertheinfluenceofvividdreamsafterawakenin,with difficultyinmakingcontactwithreality Consciousflashbacksexperiencedasintrusive,vividhallucinations(anyorall ofthesences,withpreservedinsight) Unconsciousflashbacksfeltassudden,discreteexperiencesleadingto actionsthatrepeatorrecreateatraumaticevent.

2. Avoidanceofremindersofevents 3. Emotionalnumbning,detachmentandestrangement,lossofinterestandsenseof foreshortenedfuture 4. Hyperarousalwithautonomiscsymptoms,hypervigillance,sleepdisturbance, irritability,poorconcentration MostofthebookshavedescribedalltheprovidedoptionsasfeaturesofPTSD.However hallucinationsarereclassifiedaspseudohallucination,psychotichallucination,and dissociativehallucination.BygettingintothetopicifoundthatthehallucinationsinPTSDare actuallyPseudohallucinations(withintactinsight). ReadfollowinglinesfromAGuidetoPsychiatricExaminationbyCarmeloAquilina,James Warnerpage84 Pseudohallucinationshavethevividnessoftrueperceptionbutthepatientknowsthat theyareaninternalevent,ieinsightisretained.FlashbacksinPTSDandthesocalled WidowsHallucinationhavethesequalities

PAGE512 (118)RegardingpoliovirusresponsibleforpoliomyelitisallaretrueEXCEPT: (A) Type3ismostcommoninIndia (B) Type1ismostcommoninIndia (C) Type1isresponsibleformostepidemics (D) Type2iseradicatedworldwide ANSWER:(B)Type1ismostcommoninIndia REF:Parkstextbook20theditionpage176183,Neurologicalpractice:anIndian perspectivebyWadiaPage113 Insoutheastasiaregion,Indiaistheonlycountryreportingpoliocaseswithmostof thecasesreportedfromBiharandUttarPradesh. Thereismarkedchanceintheratiooftotalnumberofwildpoliovirus1isolateto wildpoliovirus3isolatefromapproximately7:1to1:13.(duetopulsepolio programmeandvaccine) Nowildpoliovirus2hasbeendetectedanywhereintheworldsince1999 Wildpoliovirus1isresponsibleformostoftheepidemics. PAGE541 (197)MinimumhCGlevelthataurinepregnancytestcandetectis? (A) 5mIU/ml

(B) 1020mIU/ml (C) 2030mIU/ml (D) 35mIU/ml ANSWER:(A)5mIU/ml REF:Danforth'sObstetricsandGynecology,10thEditionpage4,CurrentOB/GYN>Chapter 9.NormalPregnancy&PrenatalCare>NormalPregnancy> URINEPREGNANCYTEST: Sensitive,earlypregnancytestmeasurechangesinlevelsofhCG.Thereislesscrossreaction withluteinizinghormone(LH),folliclestimulatinghormone(FSH),andthyrotropin,whichall sharecommonsubunitwithhCG,whenthesubunitofhCGismeasured.hCGisproduced bythesyncytiotrophoblast8daysafterfertilizationandmaybedetectedinthematernal serumafterimplantationoccurs,811daysafterconception.hCGlevelspeakat approximately810weeksofgestation.Levelsgraduallydecreaseinthesecondandthird trimestersandincreaseslightlyafter34weeks.ThehalflifeofhCGis2days.After terminationofpregnancylevelsdropexponentially.Normally,serumandurinehCGlevels returntononpregnantvalues(<5mU/mL)2124daysafterdelivery. hCGismeasuredinmilliinternationalunitspermilliliter(mIU/ml) Thedetectionofgreaterthan35mIUofhumanchorionicgonadotropin(hCG)inthe firstmorningvoidhasaveryhighspecificityforpregnancy HcginmIU/ml Result Under5mIU/ml NegativeNotpregnant Between525mIU/ml: "Equivocal"MaybepregnantmaynotbeRepeattest Over25mIU/ml PositivePregnant PAGE570&606 (98)ReferenceweightofIndianmenandwomenis? (A) 60and55kg (B) 60and50kg (C) 55and50kg (D) 50and45kg ANSWER:(A)60and55kg REF:Park20theditionpage547,Park21stedpage584 Note:The20theditionofparktextbookhaveolderdatarelatedtoreferenceIndianmanand womanwhichwaschangedbyICMRintheyear2011. CRITERIAFORINDIANREFERENCEMANANDWOMAN: Particulars Indianreferenceman Indianreferencewoman Age 1829years 1829years Height 1.73meters 1.61m BMI 20.3 21.2 Weight 60kg 55kg

Dailyactivities 8hoursofmoderateoccupation 8hoursofhouseholdwork 8hoursinbed 8hoursinbed 46hourssittingandmovingaround 46hourssittingandmovingaround 2hourswalkingandrecreation 2hourswalkingandrecreation Energy Lightwork=2320kcal/day Lightwork=1900kcal/day requirement Moderatework=2730kcal/day Moderatework=2230kcal/day Heavywork=3490kcal/day Heavywork=2850kcal/day Protein 1gm/day/kg 1gm/day/kg allowance Fatintake 2540gm/day 2030gm/day PAGE580&651 (209)Whichamongstthefollowinghavelongesthalflife? (A) Radon (B) Radium (C) Plutonium (D) Iridium ANSWER:(C)Plutonium REF:http://www.nrc.gov/readingrm/doccollections/factsheets/plutonium.html, AlsoseeAPPENDIX67forISOTOPESUSEDINRADIOTHERAPY Ahalflifeisthetimeinwhichonehalfoftheatomsofaradioactivesubstancedisintegrates intoanothernuclearform,hence,thetimetohalveitsradioactivestrength. Ifthedetailsofisotopesarenotprovidedthenitisassumedthattheexamineristalking aboutthemoststableisotope ThemoststableisotopeofRadonis222Rnwhichhasahalflifeof3.8days ThemoststableisotopeofRadiumis226Rawhichhasahalflifeof1622years ThemoststableisotopeofIridiumis192Irwhichhasahalflifeof74days ThemoststableisotopeofPlutoniumis244Puwhichhasahalflifeof80millionyears PAGE587 (16)GobletcellsarepresentinallEXCEPT: (A) Smallintestine (B) Largeintestine (C) Esophagus (D) Stomach ANSWER:(D)Stomach REF:http://en.wikipedia.org/wiki/Goblet_cell

RepeatfromDecember2008 Gobletcellsareglandularsimplecolumnarepithelialcellswhosesolefunctionistosecrete mucin,whichdissolvesinwatertoformmucus.Theyusebothapocrineandmerocrine methodsforsecretion. LocationsofGobletcells: Theyarefoundscatteredamongtheepithelialliningoforgans,suchastheintestinaland respiratorytracts.Theyarefoundinsidethetrachea,bronchus,andlargerbronchiolesin respiratorytract,smallintestines,thecolon,andconjunctivaintheuppereyelid. Theymaybeanindicationofmetaplasia,suchasinBarrett'sesophagus. Note:Thereareothercellsthatsecretemucus(asinthefoveolarcellsofthestomach),but theyarenotusuallycalled"gobletcells"becausetheydonothavethisdistinctiveshape. PAGE638 (170)TreatmentofT4N0M0stageofheadandneckcarcinomais? (A) Surgeryalone (B) Radiotherapyalone (C) Chemoradiation (D) SurgeryandRadiotherapy ANSWER:(D)SurgeryandRadiotherapy REF:Masteryofsurgery5thedvolume1page308,Schwartz'sPrinciplesofSurgery9th Chapter18DisordersoftheHeadandNecktable183,Bailey&Loves25theditionpage740, Harrisons18thedchapter88 RepeatinDecember2011 Currenttreatmentguidelinesforheadandnecksquamouscellcarcinomahavebeen publishedbytheNationalComprehensiveCancerNetwork(NCCN). SinglemodalitytherapyisadequateforT1&T2(stageIandII)lesions.Surgeryand radiotherapyareequallyeffective. ForT3andT4(withorwithoutN1,M1)surgeryistheprincipalmodalityfollowed bypostoperativeRadiotherapyforlesionssituatedprimarilyintheoralcavity.In contrast,forT3&T4oropharyngealmalignanciesareoftentreatedinitiallywith chemoradiation. Asinthequestionthespecificsiteisnotmentionedwehavetochooseintelligently MasteryofsurgerydescribessurgeryfollowedbyradiotherapyforallT3T4lesionsother thanoropharynx(lip,tongue,retromolartrigone,oralcavity,buccalmucosaandhard palate) BaileysaysThereisanincreasingmovetomanageextensivediseaseoftheoropharynx withchemoradiotherapy,providedthatpatientsaremedicallyfittotoleratethetoxicity.

 TX T0 Tis T1 T2 T3

ForT3&T4oropharyngealHarrisonsaysSuchpatientscanalsobetreatedwithcurative intent,butnotwithsurgeryorradiationtherapyalone.Combinedmodalitytherapy includingsurgery,radiationtherapy,andchemotherapyismostsuccessful.Itcanbe administeredasinductionchemotherapy(chemotherapybeforesurgeryand/or radiotherapy)orasconcomitant(simultaneous)chemotherapyandradiationtherapy.The latteriscurrentlymostcommonlyusedandbestevidencesupported HeadandneckcancerstagingAJCC: Thesystemisuniformforallheadandnecksitesexceptforthenasopharynx. AJCC/TNMStagingforHead&NeckCancer Primarytumor Unabletoassessprimarytumor Noevidenceofprimarytumor Carcinomainsitu Tumoris<2cmingreatestdimension Tumor>2cmand<4cmingreatestdimension Tumor>4cmingreatestdimension Primarytumorinvadingcorticalbone,inferioralveolarnerve,floorofmouth,orskinof face(e.g.,noseorchin) Tumorinvadesadjacentstructures(e.g.,corticalbone,intodeeptonguemusculature, maxillarysinus)orskinofface Tumorinvadesmasticatorspace,pterygoidplates,orskullbaseand/orencasesthe internalcarotidartery Unabletoassessregionallymphnodes Noevidenceofregionalmetastasis Metastasisinasingleipsilaterallymphnode,3cmorlessingreatestdimension Metastasisinsingleipsilaterallymphnode,>3cmand<6cm Metastasisinmultipleipsilaterallymphnodes,allnodes<6cm Metastasisinbilateralorcontralaterallymphnodes,allnodes<6cm Metastasisinalymphnode>6cmingreatestdimension Unabletoassessfordistantmetastases Nodistantmetastases Distantmetastases Tis T1 T2 N0 N0 N0 M0 M0 M0

T4(lip) T4a(oral) T4b(oral)

Regionallymphadenopathy NX N0 N1 N2a N2b N2c N3 MX M0 M1 Stage0 StageI StageII

Distantmetastases

TNMstaging

StageIII StageIVa StageIVb

T3 T13 T4a T4a T14a AnyT T4b

N0 N1 N0 N1 N2 N3 AnyN

M0 M0 M0 M0 M0 M0 M0 M1

StageIVc AnyT AnyN PAGE687 (1)Wingingofscapulaisduetodamagetothenervesupplyof? (A) Serratusanterior (B) Latissimusdorsi (C) Trapezius (D) Deltoid ANSWER:(A)Serratusanterior>(C)Trapezius

REF:Graysanatomy39theditionpage558,TextbookofOrthopaedicsandTraumabyGS Kulkarnipage2600,OperativeTechniquesinShoulderandElbowSurgerybyGeraldR. Williams,MatthewL.Ramsey,SamW.Wiesepage267 AlsoseeAPPENDIX7forBRACHIALPLEXUSLESIONS Wingingofscapulaisadeformityinwhichthevertebralborderandtheinferiorangleof scapulabecomeundulyprominent. Graysanatomyhasdescribedwingingofscapulainbothnerveinjurytoserratusanterior andtrapeziusmuscle.Soweneedtolookdownthedetailedlistofcausesofwingingof scapula. CAUSESOFWINGINGOFSCAPULA:wingingofscapulacanbeprimary,secondaryor voluntary I. Primary: (A) Neurologicaldisorders: (1) Longthoracicnervepalsy(Serratusanteriorweakness) (2) Spinalaccessorynervepalsy(Trapeziusweakness) (3) Dorsalscapularnervepalsy(Rhomboidweakness)

(B) Bonyabnormalities: (1) Osteochondromaofscapula (2) Fracturemalunion (C) Softtissuedisorders: (1) Softtissuecontractures (2) Fascioscalulohumeraldystrophy (3) Congenitalabscenceofparascapularmuscles (4) Traumaticreptureofparascapularmuscles II. III. Note: Longthoracicnerveinjury(nervetoserratusanterior)isthemostcommoncauseof wingingofscapula Serratusanteriorwingingcanbedistinguishedfromtrapeziuswingingbythe directionofscapularlaxity(fig) Secondary:Disordersofglenohumeraljoint Voluntary:Psychiatricpatientsorforsecondarygain

PAGE695 (24)hCGissecretedby? (A)Syncytiotrophoblast (B)Chorionicmembrane (C)Yolksac (D)Liver

ANSWER:(A)Syncytiotrophoblast REF:Danforth'sObstetricsandGynecology,10thEditionpage4,CurrentOB/GYN>Chapter 9 hCGisproducedbythesyncytiotrophoblast8daysafterfertilizationandmaybedetected inthematernalserumafterimplantationoccurs,811daysafterconception.hCGlevels peakatapproximately810weeksofgestation.Levelsgraduallydecreaseinthesecondand thirdtrimestersandincreaseslightlyafter34weeks.ThehalflifeofhCGis2days.After terminationofpregnancylevelsdropexponentially.Normally,serumandurinehCGlevels returntononpregnantvalues(<5mU/mL)2124daysafterdelivery. hCGismeasuredinmilliinternationalunitspermilliliter(mIU/ml) Thedetectionofgreaterthan35mIUofhumanchorionicgonadotropin(hCG)inthe firstmorningvoidhasaveryhighspecificityforpregnancy HcginmIU/ml Result Under5mIU/ml NegativeNotpregnant Between525mIU/ml: "Equivocal"MaybepregnantmaynotbeRepeattest Over25mIU/ml PositivePregnant PAGE755 (245)Additionalprotienandcalorierequirementinpregnancyis? (A)50kcal/daycalorie,10g/dayprotein (B)100kcal/daycalorie,20g/dayprotein (C)300kcal/daycalorie,30g/dayprotein (D)500kcal/daycalorie,50g/dayprotein ANSWER:(C)300kcal/daycalorie,30g/dayprotein REF:Williams22ndeditionchapter8,COGT10theditiontable91

RecommendedDailyDietaryAllowancesforNonpregnant,Pregnant,andLactating Women: Energy(kcal) NonpregnantWomen(years) 1518 1924 2550 50+ 2100 2100 2100 2000 +300 +500 PregnantWomen LactatingWomen

 Protein(g) Fatsolublevitamins VitaminA(RE)/(IU) VitaminD(IU) VitaminE(IU) VitaminC(mg) Folate(g) Niacin(mg) Riboflavin(mg) Thiamine(mg) VitaminB6(mg) VitaminB12(g) Minerals Calcium(mg) Iodine(g) Iron(mg) Magnesium(mg) Phosphorus(mg) Zinc(mg) PAGE778

NonpregnantWomen(years) 1518 1924 2550 50+ 48 800 400 8 60 180 15 1.3 1.1 1.5 2 1300 150 15 300 1200 12 46 800 400 8 60 180 15 1.3 1.1 1.6 2 1000 150 15 280 800 12 46 800 200 8 60 180 15 1.3 1.1 1.6 2 1000 150 15 280 800 12 46 800 200 8 60 180 13 1.2 1.0 1.6 2 150 10 280 800 12

PregnantWomen LactatingWomen +30 800 400 10 70 400 17 1.6 1.5 2.2 2.2 175 30 300 1200 15 +20 1300 400 12 95 280 20 1.8 1.6 2.1 2.6 1000 200 15 355 1200 19

Watersolublevitamins

1200 1000

APPENDIX6
BRACHIALARCHES
Therearesixpharyngealarches,butinhumansthefiftharchonlyexiststransientlyduring embryologicgrowthanddevelopment.Sincenohumanstructuresresultfromthefiftharch,the archesinhumansareI,II,III,IV,andVI.Thefirstthreecontributetostructuresabovethelarynx, whilethelasttwocontributetothelarynxandtrachea SKELETAL NERVE ARTERY CORROSPONDIN PHARYNGEA MUSCULAR CONTRIBUTION CONTRIBUTIONS GPOUCH LARCH S STRUCTURES 1st Musclesof (mandibular mastication, Maxilla,mandible Trigeminal (onlyasamodel nerve(V2and Maxillary artery, Eustachiantube, middleear,

arch)

Anteriorbelly ofthedigastric, Mylohyoid, Tensor tympani, Tensorveli palatini

formandiblenot V3) actualformation ofmandible), Incusand Malleus,Meckel's cartilage,Ant. ligamentof malleus, Sphenomandibul arligament

external mastoidantrum, carotidartery andinnerlayer ofthetympanic membrane.

2nd(hyoid arch)

Musclesof facial expression, Buccinator, Platysma, Stapedius, Stylohyoid, Posteriorbelly ofthedigastric

Stapes,Styloid Facialnerve(VII) Stapedial process,hyoid Artery (lesserhornand upperpartof body),Reichert's cartilage, Stylohyoid ligament

middleear, palatinetonsils

3rd

Stylopharyngeu Hyoid(greater s hornandlower partofbody), (deletethymus fromhere)

Glossopharynge Common Inferior alnerve(IX) carotid/Intern parathyroid, alcarotid Thymus

4th

Cricothyroid Thyroidcartilage, Vagusnerve(X) muscle,all epiglottic Superior intrinsic cartilage laryngealnerve musclesofsoft palateincluding levatorveli palatini Allintrinsic Cricoidcartilage, Vagusnerve(X) musclesof arytenoid Recurrent larynxexcept cartilages, laryngealnerve thecricothyroid corniculate muscle cartilage

Right4th aorticarch: subclavian artery

Superior parathyroid, ultimobranchial body(which formsthePara Left4thaortic follicularCCells ofthyroidgland) arch:aortic arch Rudimentary structure, becomespartof thefourthpouch contributingto Left6thaortic thyroidCcells. arch: Pulmonary arteryand ductus arteriosus

6th

Right6th aorticarch: pulmonary artery

 PAGE784 APPENDIX10(NEWANDIMPROVED,replacewitholderone) SOMEIMPORTANTEPITHELIUMLININGS: System Tissue Epithelium Circulatory Digestive Digestive Digestive Digestive Bloodvessels,Lymphvessels Ductsofsubmandibularglands Gingiva,Dorsumoftongue,Hard palate, Oesophagus Stomach,Smallintestine,Large intestine,Rectum,Gallbladder Anus Thyroidfollicles Ependyma Skinsuperficiallayer Sweatglandducts Mesotheliumofbodycavities Fallopiantubes,Endometrium (uterus) Simplesquamous Stratifiedcolumnar Stratifiedsquamous,keratinized Stratifiedsquamous,nonkeratinized Simplecolumnar,nonciliated Stratifiedsquamous,nonkeratinized superiortoHilton'swhiteline Stratifiedsquamous,keratinizedinferior toHilton'swhiteline Simplecuboidal Simplecuboidal Stratifiedsquamous,keratinized Stratifiedcuboidal Simplesquamous Simplecuboidal Simplecolumnar,ciliated Simplecolumnar Stratifiedsquamous,nonkeratinized Stratifiedsquamous,keratinized Simplecuboidal Pseudostratifiedcolumnar Pseudostratifiedcolumnar,with stereocilia Simplecolumnar Stratifiedsquamous,nonkeratinized Pseudostratifiedcolumnar,ciliated Stratifiedsquamous,nonkeratinized Simplecuboidal Stratifiedsquamous,nonkeratinized Pseudostratifiedcolumnar

Digestive Endocrine Nervous Integumentary Integumentary Integumentary

Reproductivefemale Ovaries Reproductivefemale

Reproductivefemale cervix(endocervix) Reproductivefemale cervix(ectocervix),Vagina Reproductivefemale Labiamajora Reproductivemale Reproductivemale Reproductivemale Reproductivemale Respiratory Respiratory Respiratory Respiratory Sensory Sensory Retetestis Ductuliefferentes,Vasdeferens, Seminalvesicle Epididymis Ejaculatoryduct oropharynx,Lingualepiglottis Larynx,Laryngealepiglottis, Trachea LarynxTruevocalcords Respiratorybronchioles Cornea Nose

System Urinary Urinary Urinary Urinary Urinary Urinary Urinary PAGE796

Tissue KidneyPCT KidneyAscendingthinlimb KidneyDCT KidneyCollectingduct Renalpelvis,Ureter,Urinary bladder,Prostaticurethra, Membranousurethra,Penile urethra Externalurethralorifice

Epithelium Simplecuboidal,withmicrovilli Simplesquamous Simplecuboidal,withoutmicrovilli Simplecuboidal Transitional Pseudostratifiedcolumnar,nonciliated Stratifiedsquamous

APPENDIX19
CYTOKINES:

NAME IFN, IFN TNF TNF,LT (lymphotoxin) IL1 IL2 IL3 IL4 IL5 IL6 MAJORCELLULARSOURCE Macrophages(IFN) fibroblasts(IFN) CD4+Tcells,NKcells Macrophages,Tcells Tcells Macrophages Tcells Tcells Tcells,mastcells Tcells Tcells,Macrophages SELECTEDBIOLOGICEFFECTS Antiviral Activatesmacrophages,TH1differentiation Cellactivation,Fever,cachexia,antitumor ActivatesPMNs Cellactivation,Fever(Proinflammatory) Tcellgrowthandactivation Hematopoiesis BcellproliferationandswitchingtoIgE,TH2 differentiation Differentiationofeosinophil,activatesB cells Bothproinflammatoryandanti inflammatory,mediatoroffever&acute phaseresponse Tcellprogenitordifferentiation Chemotacticforneutrophils Inhibitsactivatedmacrophagesand dendriticcells,Antiinflammatory DifferentiationofTcells,activationofNK cells Differentiationofmyeloidprogenitorcells Differentiationofmonocytesand macrophages Stimulatesneutrophilproductioninbone marrow

IL7 IL8 IL10 IL12 GMCSF MCSF GCSF

Bonemarrowstromacells Macrophages,Tcells Macrophages,Tcells Macrophages Tcells,macrophages,monocytes Macrophages,monocytes, fibroblasts Fibroblasts,monocytes, macrophages

 PAGE798

APPENDIX21
HYPERSENSITIVITYREACTIONS
TrueAnaphylaxis Wheal&Flarereaction,Casonistest, FreeAgfixedIgE(onmastcell anaphylaxis,prusnitzkunsterreaction, Theobaldsmithphenomenon,Schultzdale phenomenon,Atopicdermatitis, Iodinecontainingradiocontrast(mc),aspirin Pseudoanaphylaxis andmusclerelaxants,morphine (Anaphylactoidreaction) FreeAgdirectdegranulation ofmastcell(notIgEmediated) Free TYPE2: IgMIgG/ Autoimmunehemolyticanemia AbfixedAg Complement Antibody Hemolyticdiseaseofthenewborn dependent mediated (erythroblastosisfetalis) cytotoxic Autoimmunethrombocytopenicpurpura hypersensitivity Goodpasture'ssyndrome Pemphigusvulgaris Bullouspemphigoid Acuterheumaticfever Perniciousanemia Myastheniagravis Gravesdisease ADCC Acute&chronictransplantrejection antibody dependent cellmediated cytotoxicity TYPE3:Immune FreeAg+FreeAbImmune Serumsickness complex complex Arthusreaction Systemiclupuserythematosus(SLE) Immunoglobulintherapy Hyperacutegraftrejection Acutenecrotizingvasculitis Polyarteritisnodosa Poststreptococcalglomerulonephritis Shickstest Delayed:CD4 Contactdermatitis TYPE4:Delayed Ag+Tcell Mantoux(tuberculin)test hypersensitivity, mediated mediated (CD4/CD8) Lepromintest cellmediated, [contact& Acutetransplantrejection antibody tuberculin Multiplesclerosis independent typeswithin Phlyctenularkeratoconjunctivitis 72hours, Granulomatous Jonesmotereaction(cutaneousbasophilic hypersensitivity) type;2128 TYPE1: Allergy/Atopy/ Anaphylaxis

days]

Directcell toxicity:CD8 mediated

Perforindependentkilling FasFasLdependentkilling

Alsoknow:Graftrejectionistype4hypersensitivityunlesstypeisprovided.(MostoftheMCQ guideshavequotedthisfalsely) Hyperacute Type3 Acute Type4>2(bothifprovided) Acutecellularrejection=type4(betterprognosis) Acutevascularrejection=type2 Chronic Type2 PAGE816

APPENDIX33
CHEMICALKINETICSOFDRUGS

Rateof reaction Zeroorderkinetics Rateofreactionis independentofthe concentrationofthe reactant(s) Constantamountofdrug eliminationperunittime Independentofplasma concentration(i.e. Constantwith concentration) Firstorderkinetics Rateofreactionis proportionaltothe concentrationofonlyone reactant Constantfractionofdrug eliminationperunittime Proportionaltoplasma concentration(i.e.Lessat lowconcentration, Moreathigh concentration) Secondorderkinetics Rateofreactionis proportionaltothe concentrationsofone secondorderreactant,or twofirstorderreactants. Proportionaltothe concentrationofthe squareofasinglereactant ortheproductofthe concentrationoftwo reactants

Rateof elimination / Clearance

Halflife

Example

T=[A0]/2K T=0.693/K Lessatlowconcentration I.e.TisConstant, Moreathighconcentration tdependsonKonly tisindependentof initialconcentration Mnemonic=ZeroWATT Mostofthedrugsfollows

T=1/K[A0] Eachsuccessivehalflifeis doubletheprecedingone. tdependsonbothKand initialconcentration Gasphasedecomposition

Graph

Power firstorderkinetics Zeroorderkinetics by W=warfarin A=Alcohol,Aspirin T=Theophylline T=Tolbutamide Power=Phenytoin Linearrelationship betweentimefrompeak concentrationandplasma concentration

ofNO2(2NO22NO+O2)

PAGE852

APPENDIX57
TYPESOFNERVEINJURY

Sunderlandclassificationofinjuriesdescribesthreetypes:neuropraxia,axonotmesis,and neurotmesis. Severity Pathology Neuropraxia Leastsevere myelin physiologicblockof impulseconduction Axon Endoneurium withoutanatomic Perineurium destruction Epineurium Electrical EMG Normal phenomena Distal Preserved conduction Motorunit Absent action potential Walleriandegeneration Absent Neuroma Absent Lossesdistaltoinjury Motor>sensory, Axonotmesis Severe Lost Lost Intact Intact Intact Fibrillations Absent Absent Neurotmesis Mostsevere Lost Lost Lost Lost Occasionallyintact Fibrillations Absent Absent

Present Neuromain continuity Allsensorymotor&

Present Endneuroma Allsensorymotor&

Example Recovery

Autonomicintact Pressure Ischemia Repair Notrequired Rate Hourstoweeks, spontaneous Motormarch Absent(noorder) Quality Perfect

autonomic Crashinjury Notnecessary 12mm/dayafter repair Asperorderof innervation Perfect

autonomic Transection,stretch, laceration,LAtoxicity Necessary 12mm/dayafter repair Asperorderof innervation Alwaysimperfect/ incomplete

PAGE866

APPENDIX68
ALPHABETICALLISTOFEPONYMOUSFRACTURES
Fracture Description Aviatorsfracture Fractureneckoftalus Bumperfracture Mechanismofinjury Dorsiflexion

compressionfractureoflateralcondyleoftibial(alwaysForcedvalgusofkneewhenstruck intraarticular) fromsidebycarbumper Boxer'sfracture Fractureofdistal5thmetacarpal Punchingsolidobject Bosworthfracture Fractureofdistalfibulawithposteriordislocationof Severeexternalrotationofthe theproximalfibulabehindthetibia foot Bennett'sfracture Intraarticularfractureofbaseoffirstmetacarpal Axialloadalongmetacarpalina partiallyflexedthumb(Abductor pollicislonguspull) Barton'sfracture Intraarticulardistalradiusfractureinvolvingthe Fallonoutstretchedhand articularsurfacewithdislocationoftheradiocarpal joint Bankart'sfracture Fractureofanteriorglenoidassociatedwithanterior Externalrotationandabductionof shoulderdislocation shoulder Colles'fracture Distalradiusfracturewithdorsalangulation,impaction Fallonoutstretchedhand andradialdrift Cottonsfracture Trimalleolarfractureofankle Clayshoveller's StressavulsionfractureofSpinousprocessofC6,C7or Forcedhyperflexionofneck fracture T1 Chopart'sfracture Footdislocationthroughtalonavicularand dislocation calcaneocuboidjointswithassociatedfractures,usually afterankletwisting.Treatedinanonweightbearing castfor68weeks Chauffeur'sfractureIntraarticularfractureofradialstyloid Forcedulnardeviationofthewrist causingavulsionoftheradial styloid Chancefracture Horizontalfractureofvertebralbody Hyperflexionofspine,seenincar accidentswhenlapbeltswere used

Duverneyfracture Isolatedfractureoftheiliacwing Directtrauma EssexLopresti Comminutedradialheadfracturewithinterosseous Fallfromheight fracture membranedisruptionanddistalradioulnarjoint subluxation Gosselinfracture Vshapeddistaltibiafractureextendingintothetibial plafond Galeazzifracture Radiusshaftfracturewithdislocationofdistal radioulnarjoint HoldsworthfractureUnstablespinalfracturedislocationatthe thoracolumbarjunction Humefracture Olecranonfracturewithanteriordislocationofradial head HillSachsfracture Impactedposteriorhumeralheadfractureoccurring duringanteriorshoulderdislocation Hangman'sfracture FractureofbothpediclesofC2 Jonesfracture Fractureofbaseof5thmetatarsalextendinginto intermetatarsaljoint Jeffersonfracture Burstfractureof1stcervicalvertebra Lisfrancfracture Fracturedislocationofmidfoot Blowtoforearm

Distractionandextensionofneck (judicialhanging) Inversionofankle(pronatorbrevis pull) Compressionofneck Forcedplantarflexionoffootor droppingheavyweightonfoot

LeFort'sfractureof Verticalfractureofdistalfibulawithavulsionofmedial theankle malleolus LeFortfractures Seriesoffacialfractures Directtraumatoface Moore'sfracture Distalradiusfracturewithulnardislocationand entrapmentofstyloidprocessunderannularligament Monteggiafracture Proximalulnafracturewithdislocationofradialhead Blowtoforearm Marchfracture Stressfractureof2nd/3rdmetatarsalshaft Heavyorunaccustomedexercise Malgaigne'sfractureVerticalpelvicfracturethroughbothpubicramiand Highenergyimpacttopelvis theiliumorsacroiliacjointwithverticaldisplacement (fronttoback) Maisonneuve Spiralfractureofproximalfibula Externalrotationofankle fracture Pipkinfracture Posteriordislocationofhipwithavulsionfractureof Impacttothekneewiththehip dislocation fragmentoffemoralheadbytheligamentumteres flexed(dashboardinjury) Pilon(Hammer) Intraarticularfractureoftibialplafond.UsuallybutnotHighvelocityinjuries fracture alwayswithfibularfracture.Usuallybutnotalways withfibularfracture Pott'sfracture Bimalleolarfractureoftheankle Eversionofankle Rolandofracture IntraarticularTorYshapedComminutedfractureof Axialloadalongthemetacarpal baseof1stmetacarpal causingsplittingoftheproximal articularsurface Runner'sfracture Stressfractureofdistalfibula38cmabovethelateral Repeatedaxialstressonfibula malleolus Stiedafracture Avulsionfractureofthemedialfemoralcondyleatthe originofthemedialcollateralligament Smith'sfracture Distalradiusfracturewithvolardisplacement Fallonoutstretchedhandwith wristinflexedposition Shepherd'sfracture Fractureofthelateraltubercleoftheposteriorprocess ofthetalus Segondfracture Lateraltibialplateauavulsionfracturewithanterior Internalrotationoftheknee

cruciateligamenttear SalterHarris Fracturesinvolvingagrowthplate fractures Tillauxfracture SalterHarrisIIIfractureofthetibia Toddler'sfracture Undisplacedspiralfractureofdistaltibiainchildren under8yearsold PAGE871

various Forcedlateralrotationoffoot Lowenergytrauma,often rotational

APPENDIX70
HEALTHRELATEDDAYS:
Worldleprosyday Worldcancerday Worlddisabledday WorldTBday WorldHealthday WorldMalariaday Redcrossday Worldnotobaccoday AntiFilariaday Worldblooddonationday Internationaldayagainstdrugabuse Worlddiabetesday WorldZoonosisday Worldpopulationday Worldbreastfeedingweek Suicidepreventionday Alzheimersday WorldRabiesday WorldHeartday Internationaldayforelderly Mentalhealthday Etherday/Anesthesiaday Worlddiabetesday WorldRTAday WorldCOPDday AIDSday Hepatitisday Note: On20December2006,theUnitedNationsGeneralAssemblypassedResolution61/225.It designates14November,thecurrentWorldDiabetesDay. 30January 4thFebruary 15thMarch 24thMarch 7thApril 25thApril 8thMay 31stMay 5thJune 14thJune 26thJune 27thJune 6thJuly 11thJuly 17August 10thSeptember 21stSeptember 28thSeptember 29thSeptember 1stOctober 10October 16thOctober 14thNovember 16thNovember 19thNovember 1stDecember 4thDecember

EarlierWHOannounced14thnovenberasworlddiabetesdayintheyear1998. From1991to1998WHOcelebratedworlddiabetesdayon27thJune. InIndiatheworlddiabetesdayisstillcelebratedon27thofJuneeveryyear.