NMBE 1

Block 1

1 B

In pathology, a granuloma (classical Greek plural granulomata; modern anglicized plural granulomas) is an
organized collection of macrophages.

Macrophages (also known as histiocytes) are the cells that define a granuloma. They often, but not invariably, fuse
to form multinucleated giant cells.[5] The macrophages in granulomas are often referred to as "epithelioid". This term
refers to the vague resemblance of these macrophages to epithelial cells. Epithelioid macrophages differ from
ordinary macrophages in that they have elongated nuclei that often resemble the sole of a slipper or shoe. They also
have larger nuclei than ordinary macrophages and their cytoplasm is typically more pink when stained with eosin.
These changes are thought to be a consequence of "activation" of the macrophage by the offending antigen.

2.C

3 B

1
2
4E Barret’s esophagus GERD

3
 3

5.B

Swelling within seconds after coronary occlusion

6 A Parkinson’s disease
B Huntington’s disease
C AIDs dementia
D Alzhiemers Disease
E PML

7 I S4 LATE diastolic SOUND so they are talking about S3 or S4; in case of hypertension we have S4
http://en.wikipedia.org/wiki/Heart_sounds
The rare fourth heart sound is sometimes audible in healthy children and again in trained athletes, but when audible in
an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a
stiff/hypertrophic ventricle. It is a sign of a pathologic state, usually a failing left ventricle, but can also be heard in other
conditions such as restrictive cardiomyopathy. The sound occurs just after atrial contraction ("atrial kick") at the end of
diastole and immediately before S1, producing a rhythm sometimes referred to as the "Tennessee" gallop where S4
represents the "tenn-" syllable. It is best heard at the cardiac apex with the patient in the left lateral decubitus
position and holding his breath. The combined presence of S3 and S4 is a quadruple gallop. At rapid heart rates, S3
and S4 may merge to produce a summation gallop (sometimes referred to as S7).

8 E PRPP
A SCID

9 A
Anticipation Myotonic dystrophy is non-polyQ disease CTG repeats
Family studies have also suggested that these diseases are associated with anticipation, the tendency for progressively
earlier or more severe expression of the disease in successive generations

.Over half of these disorders the repeated codon is CAG , which in a coding region , and codes for glutamine ( Q ),
resulting in a polyglutamine tract. These diseases are commonly referred to as polyglutamine ( or PolyQ ) diseases .
The remaining disorders repeated codons do not code for glutamine and are classified as non - polyglutamine diseases

4
A common symptom of PolyQ diseases is characterized by a progressive degeneration of nerve cells usually affecting
people later in life. Although these diseases share the same repeated codon (CAG) and some symptoms, the repeats for
the different polyglutamine diseases occur on different chromosomes.

The non-PolyQ diseases do not share any specific symptoms and are unlike the PolyQ diseases

Triplet expansion is caused by slippage during DNA replication. Due to the repetitive nature of the DNA sequence in these
regions, 'loop out' structures may form during DNA replication while maintaining complementary base paring between the
parent strand and daughter strand being synthesized. If the loop out structure is formed from sequence on the daughter
strand this will result in an increase in the number of repeats. However if the loop out structure is formed on the parent
strand a decrease in the number of repeats occurs. It appears that expansion of these repeats is more common than
reduction. Generally the larger the expansion the more likely they are to cause disease or increase the severity of
disease. This property results in the characteristic of anticipation seen in trinucleotide repeat disorders. Anticipation
describes the tendency of age of onset to decrease and severity of symptoms to increase through successive generations
of an affected family due to the expansion of these repeats.
10 E surreptitious use of insulin health care worker , serum C peptide concentration is not detectable
11 D stringency - conscientious attention to rules and details that ‘s why mismatched DNA hybridization is
prevented. under hign stringency we want to prevent any mismatches. I mean we want to create the most
pure DNA. that's what high stringency means.

12 E Oligohydramnius can’t pee

13 B “Tell me more………”
14 B Like many other first-generation antihistamines, diphenhydramine is a potent anticholinergic agent. This leads to
profound drowsiness as a very common side-effect. Diphenhydramine has also been used as an anxiolytic because of
these sedating side effects. However, other side effects include possibilities of motor impairment (ataxia), dry mouth and
throat, flushed skin, rapid or irregular heartbeat (tachycardia), blurred vision at nearpoint owing to lack of
accommodation (cycloplegia), abnormal sensitivity to bright light (photophobia), pupil dilation (mydriasis), urinary
retention, constipation, difficulty concentrating, short-term memory loss, visual disturbances, hallucinations, irregular
breathing, dizziness, irritability, itchy skin, confusion, decreased body temperature (generally in the hands and/or feet),
erectile dysfunction, excitability, and delirium
A Is H2 blocker
D Guaifenesin is expectorant

15 B hot nodule--- toxic nodular goiter---adenoma

Cold nodule it will be Follicular carcinoma

Nodules detected by thyroid scans are classified as cold, hot, or warm. Thyroid cells absorb iodine so they can make
thyroid hormone out of it. When radioactive iodine is given, a butterfly image will be obtained on x-ray film showing the
outline of the thyroid. If a nodule is composed of cells that do not make thyroid hormone (don't absorb iodine), then it
will appear "cold" on the x-ray film. A nodule that is producing too much hormone will show up darker and is called "hot."

85% of thyroid nodules are cold, 10% are warm, and 5% are hot. Remember that 85% of cold nodules are benign, 90%
of warm nodules are benign, and 95% of hot nodules are benign.

16 D
17 A
18 B
19 C
Fludrocortisone (also called 9α-fluorocortisol) is a synthetic corticosteroid with moderate glucocorticoid potency and
much greater mineralocorticoid potency

Uses
1. Fludrocortisone has been used in the treatment of cerebral salt wasting.
2. It is used primarily to replace the missing hormone aldosterone in various forms of adrenal insufficiency such as
Addison's disease and the classic salt wasting (21-hydroxylase deficiency) form of congenital adrenal hyperplasia.
3. Fludrocortisone is the first line of treatment for orthostatic intolerance as well.
4. Fludrocortisone is also a confirmation test for diagnosing Conns Syndrome (aldosterone producing-adrenal
adenoma), the fludrocortisone suppression test. Loading the patient with fludrocortisone would suppress serum
aldosterone level in a normal patient, whereas the level will not be altered in a Conns patient.

Chemical properties
Chemically, fludrocortisone is identical to cortisol except for the substitution of fluorine in place of one hydrogen.
Fluorine is a good bioisostere for hydrogen because it is similar in size. The major difference is in its electronegativity.

Side effects
Sodium and water retention
Swelling due to fluid retention (edema)
High blood pressure (hypertension)
5
Headache
Low blood potassium level (hypokalemia)
Muscle weakness
Fatigue
Increased susceptibility to infection
Impaired wound healing
Increased sweating
Increased hair growth (hirsutism)
Thinning of skin and stretch marks
Disturbances of the gut such as indigestion (dyspepsia), distention of the abdomen and ulceration (peptic ulcer)
Decreased bone density and increased risk of fractures of the bones
Difficulty in sleeping (insomnia)
20 B

B - Fallopian Tube.
Ectopic pregnancy due to pelvic inflammatory disease. Right lower quadrant pain increases the likelihood of appendicitis,
ectopic pregnancy, ovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.

21 C

CHRONIC GRANULOMATOUS DISEASE (CGD)

Defective NADPH oxidase system (mutation in any of
the four enzymes) impairs the production of reactive
oxygen intermediates required for phagocyte killing.
As a result, phagocytes can internalize bacteria but
are unable to kill certain classes. This malfunction
causes accumulations of immune cells in granulomas,
which form at the site of infection.
Myeloperoxidase deficiency is often considered a
milder form of CGD.

PRESENTATION
Severe catalase-positive bacterial infections (e.g.,
Staphylococcus aureus) and/or fungal infections,
especially of the skin; hepatosplenomegaly; and
lymphadenopathy.

DIAGNOSIS
Phagocyte function is determined using a test of the ability to reduce nitroblue tetrazolium dye. The specific defect is
determined by genetic testing.

TREATMENT
Bone marrow transplantation can be curative. IFN-γ and prophylactic antibiotics are the current standard of care.

PROGNOSIS
Depends on severity of disease; highest mortality is seen in children.
MYELOPEROXIDASE DEFICIENCY
The myeloperoxidase pathway is not critical for phagocyte function, and affected individuals are often asymptomatic and
undiagnosed; it can present as a somewhat milder form of CGD. This deficiency may be inherited or acquired. Acquired
forms are generally transient.

6
Antibodies against MPO have been implicated in various types of vasculitis, most prominently crescentic
glomerulonephritis and Churg-Strauss syndrome. They are detected as perinuclear ANCAs (pANCAs), as opposed to the
cytoplasmic ANCAs (cANCAs) against proteinase 3 (PR3), which are strongly associated with Wegener's granulomatosis
Immunohistochemical staining for myeloperoxidase used to be administered in the diagnosis of acute myeloid leukemia
to demonstrate that the leukemic cells were derived from the myeloid lineage. However, the use of myeloperoxidase
staining in this setting has been supplanted by the widespread use of flow cytometry.

22 C

NO is one of the few gaseous signaling molecules known. Nitric oxide, known as the 'endothelium-derived relaxing
factor', or 'EDRF', is biosynthesized endogenously from L-arginine and oxygen by various nitric oxide synthase (NOS)
enzymes and by reduction of inorganic nitrate. The endothelium (inner lining) of blood vessels uses nitric oxide to signal
the surrounding smooth muscle to relax, thus resulting in vasodilation and increasing blood flow. Nitric oxide is highly
reactive (having a lifetime of a few seconds), yet diffuses freely across membranes. These attributes make nitric oxide
ideal for a transient paracrine (between adjacent cells) and autocrine (within a single cell) signaling molecule. The
production of nitric oxide is elevated in populations living at high altitudes, which helps these people avoid hypoxia by
aiding in pulmonary vasculature vasodilation.
Effects include vasodilatation, neurotransmission (see gasotransmitters), modulation of the hair cycle, production of
reactive nitrogen intermediates and penile erections (through its ability to vasodilate). Nitroglycerin and amyl nitrite
serve as vasodilators because they are converted to nitric oxide in the body. Sildenafil citrate, popularly known by the
trade name Viagra, stimulates erections primarily by enhancing signaling through the nitric oxide pathway in the penis.

http://en.wikipedia.org/wiki/Nitric_oxide

http://www.google.com/imgres?imgurl=http://www.cvphysiology.com/Blood%2520Flow/BF011%2520-%2520nitric
%2520oxide.gif&imgrefurl=http://www.cvphysiology.com/Blood
%2520Flow/BF011.htm&usg=__zLqpegS8Gzlx64rJftaLjVbzW0Y=&h=267&w=325&sz=17&hl=en&start=1&um=1&itbs=1
&tbnid=uuxY-dmb-97BUM:&tbnh=97&tbnw=118&prev=/images%3Fq%3Dnitric%2Boxide%26um%3D1%26hl%3Den
%26client%3Dfirefox-a%26sa%3DN%26rls%3Dorg.mozilla:en-US:official%26tbs%3Disch:1

23 E
http://en.wikipedia.org/wiki/Pick%27s_disease

Pick's disease, also known as Pick disease and PiD, is a rare neurodegenerative disease. While the term Pick's disease
was once used to represent a specific group of clinical syndromes with symptoms attributable to frontal and temporal
lobe dysfunction, it is now used (at least among professionals in the field) to mean a specific pathology that is just one of
the causes of the clinical syndrome now known as frontotemporal lobar degeneration.

7
Differences from Alzheimer’s disease
In Alzheimer’s disease, all six isoforms of tau proteins are expressed. In addition, the presence of neurofibrillary tangles
that are a hallmark of Alzheimer’s can be stained with antibodies to basic fibroblast growth factor, amyloid P, and
heparan sulfate glycosaminoglycan. Another difference is that in Pick's disease, a personality change occurs prior to any
form of memory loss, unlike Alzheimer's, where memory loss typically presents first. This is used clinically to determine
whether patient is suffering from Alzheimer's or Pick's.

Frontotemporal dementia (FTD) is a clinical term that refers to a group of progressive neurodegenerative disorders that
affect the frontal and temporal lobes causing personality change (apathy, disinhibition, loss of insight and emotional
control), loss of the ability to recognize the meaning of words and objects, language dysfunction, and global cognitive
decline. FTDs have an earlier onset than AD and, at an early stage, do not cause the memory loss and visuo-spatial
disorientation that are so characteristic of AD.

TAUOPATHIES
Tau (the Greek letter) is a microtubule associated protein, encoded by the gene MAPT gene on 17q21.
Normally, tau is phosphorylated and is present mainly in axons where it binds and stabilizes microtubules.
Tauopathies are characterized by abnormal deposits of hyperphosphorylated tau in the form of paired helical
or straight filaments. The tauopathies include:
Pick's Disease
Frontotemporal Dementia with Parkinsonism Linked to Chromosome 17
(FTDP-17)
Corticobasal Degeneration
Progressive supranuclear palsy
AD is also in part a tauopathy. In AD, the tau deposits (NFTs and neuropil threads) are present in the neuronal body and
dendrites. In other tauopathies, both, neurons and glial cells are affected. Hyperphosphorylation of the tau protein (tau
inclusions), however, can result in the self-assembly of tangles of paired helical filaments and straight filaments, which
are involved in the pathogenesis of Alzheimer's disease and other Tauopathies

8
 PICK’S DISEASE
It presents between 45-65 years with
confusion and FTLD symptoms and has a
progressive course lasting 2-5 years,
sometimes more. In advanced stages it
cannot be distinguished clinically from
AD. The brain shows atrophy of frontal
and temporal lobes, Pick bodies (tau-
positive spherical cytoplasmic neuronal
inclusions, composed of straight
Pick's disease: Left: lobar atrophy. Right: Pick filaments), and Pick cells (ballooned
Pick cell
inclusion bodies. neurons with dissolution of chromatin).
Older patients may also have AD pathology.

http://www.google.com/imgres?imgurl=http://neuropathology.neoucom.edu/chapter9/images9/9-
9.jpg&imgrefurl=http://neuropathology.neoucom.edu/chapter9/chapter9cFTD.html&usg=__cwvSQVE5M82
W3ebbjp00KhKc1Uo=&h=265&w=662&sz=90&hl=en&start=2&um=1&itbs=1&tbnid=R_nxrnQM8pkxwM:&t
bnh=55&tbnw=138&prev=/images%3Fq%3Dpick%2527s%2Bdisease%26um%3D1%26hl%3Den
%26client%3Dfirefox-a%26sa%3DN%26rls%3Dorg.mozilla:en-US:official%26tbs%3Disch:1

24 C

DiGeorge syndrome

22q11.2 deletion syndrome, also known as DiGeorge syndrome, DiGeorge anomaly[2][3], velo-cardio-facial
syndrome, Shprintzen syndrome, conotruncal anomaly face syndrome, Strong syndrome, congenital thymic
aplasia, and thymic hypoplasia is a syndrome caused by the deletion of a small piece of chromosome 22.

C ardiac Abnormality (especially tetralogy of Fallot)

A bnormal facies
T hymic aplasia
C left palate
H ypocalcemia.

http://emedicine.medscape.com/article/135711-diagnosis

Evaluation of humoral immunity reveals variable immunoglobulin levels and depends on the extent of T-cell deficiency.
As would be expected (ie, because normal B-cell development requires normal T-cell function), the B-cell repertoire is
normal in patients whose only measurable T-cell defect is a low number. Patients with partial DiGeorge anomaly generate
good antibody response to protein vaccines, but no data are available on polysaccharide vaccines. Increased prevalence
of immunoglobulin A deficiency has been observed in 4 of 32 patients with 22q11.2 deletion
25

9
Much of the hydrogen peroxide that is produced during oxidative cellular metabolism comes from the breakdown of one
of the most damaging ROS, namely the superoxide anion radical (O2-). Superoxide is broken down by superoxide
dismutases into hydrogen peroxide and oxygen. Superoxide is so damaging to cells that mutations in the superoxide
dismutase enzyme can lead to ALS, which is characterised by the loss of motoneurons in the spinal cord and brain stem,
possibly involving the activation of caspase-12 and the apoptosis cascade via oxidative stress.

Antioxidant enzymes, including catalase, form the first line of defence against free radicals, therefore their regulation
depends mainly upon the oxidant status of the cell. However, there are other factors involved in their regulation,
including the enzyme-modulating action of various hormones such as growth hormone, prolactin and melatonin.

Melatonin is a derivative of the amino acid tryptophan that acts as a neurohormone in mammals, but is also synthesized
by many other species, including plants, algae and bacteria. Melatonin has been shown to markedly protect both
membrane lipids and nuclear DNA from oxidative damage. Melatonin can directly neutralise several ROS, including
hydrogen peroxide. It can also stimulate various antioxidant enzymes, including catalase, either by increasing their
activity or by stimulating gene expression for these enzymes. The decrease in melatonin levels observed with age
correlates with an increase in neurogenerative disorders such as Parkinson’s disease, Alzheimer’s disease, Huntington’s
disease and stroke, all of which may involve oxidative stress. In general, the production of ROS increases with aging and
is associated with DNA damage to the tissues.
By contrast, growth hormone, and possibly prolactin, was found to decrease catalase and other antioxidant
enzymes in various tissues in mice, suggesting that this hormone acts as a suppressor of key antioxidant compon

E-
They told to compare with the Childless women. So we have to treat the Childless women so Absolute Risk Treatment
group will be childless women. So ART = 180/1000
Now here they took control as the childbearing women. So Absolute Risk Control or ARC = 120/1500

So Relative Risk = ART /ARC = 180/1000 ÷ 120/1500 = 2.25

The incidence of cancer over total time period of the study among childless women 180/1000 or .18 or 18%, while the
incidence among those with children is 120/1500 or .08 or 8%. So RR is .18/.08= 2.25 showing that women who were
childless were 2.25 times more likely to contract lung cancer than women who have children.
formula for relative risk
RR = (numerator) a / a + b divided by (denominator) c / c + d
difficulty here is only in defining who is who...
Relative risk is probability of getting disease in the exposed group compared to the unexposed group...But in this
question defining who is exposed who is not a little bit difficult...
Look at this by this way:
as the question asks the relative risk ratio for development of breast cancer in childless woman compared with who have
children?
so our numerator is childless women
our denominatior is women who have children

a = childless women with breast cancer = 180

b = childless women without breast cancer = 820
c = women who have children and have breast cancer = 120
d = women who have children and don't have breast cancer = 1380

rest is just calculation:

10
180 / 180 + 820 divided by 120 / 120 + 1380 = 2,25

So correct answer is 2,25

E
RR=disease in exposed/disease in unexposed
Childless/with children
(180/1000)÷(120/1500)=2,25

27 F

Bilateral white patchy OHL lesions located predominantly on the lateral aspect on the tongue. The lesions did not remove
when scraped with a tongue blade.
28 A
29 D
30 D
E True hermaphroditism is a medical term for an intersex condition in which an individual is born with ovarian and
testicular tissue.

There may be an ovary on one side and a testis on the other, but more commonly one or both gonads is an ovotestis
containing both types of tissue.

It is rare — so far undocumented — for both types of gonadal tissue to function. Encountered karyotypes are 47XXY,
46XX/46XY, or 46XX/47XXY.

Although similar in some ways to mixed gonadal dysgenesis, the conditions can be distinguished histologically.

31 D HUS
Shiga toxin or shiga like toxin lead to endothelial damage swell ing and narrowing of the lumen
Endothelial cell damage subsequently potentiates renal microvascular thrombosis by promoting activation of
the blood coagulation cascade.
A RPGN
B Goodpasture

32 D
33 A
pseudohyphae at 20 and germ tubes at 37

11
34 H
35 A

36 E
37 A vit D deficiency due to malabsorption inc PTH ----INC osteoblasic act ---inc osteoblastic?
Vit D Increase osteoblastic activity
Goljan 494
Inc PTH inc activity of 1alpha hydroxylase –inc 1,25 cholecalciferol ---inc absorption of Phosphorus and Calcium but they
cannot reach the normal values

38 D Early awakening, sex , weight in the low-normal range

39 B
Auranofin is Gold containing antirheumatoid arthritis medication
40 B it is positive distribution and because it is not one line it shouldn’t be + 1 so the only choice here which also + is+
0, 6

41 E
FDA
REGULATES BOTH Efficacy and safety of drugs
Preclinical animal studies:
Results include Data on
1. organ system toxicity
2. mutagenic<AMES test> and carcinogenic potential
3. effect on reproductive performance
4. effectiveness of drug
clinical testing:
after IND exemption
 Phase 1: safety:
The drug is tested in a few healthy volunteers . pharmacokinetic properties
 Phase 2: does it work/effectiveness
100/more pts in comparision with placebo/+control
Single/double blinded
 Phase 3:how well does it work/common side effects
12
 The drug is typically tested in 1000/ more pts , in comparision with placebo and positive control usually double-blind
Phase 4:follows a NDA, a request for marketing approval, and involves pms of adverse effects.
Quantifies common side effects,reveal less common and more severe toxicities that could warrant withdrawal

42 D First of all, most of the bacterial polysaccharides are T-lymphocyte independent antigens. Antipolysaccharide
immune response is characterised by lack of T-lymphocyte memory, isotype restriction and delayed ontogeny.
Children below 2 years of age and elderly respond poorly to polysaccharide antigens. Secondly, the wide structural
heterogeneity among the polysaccharides within and between species is also a problem. Thirdly, some bacterial
polysaccharides are poor immunogens in humans due to their structural similarities with glycolipids and glycoproteins
present in man. The T-lymphocyte independent nature of a polysaccharide may be overcome by conjugating the native
or depolymerised polysaccharide to a protein carrier. Such neoglycoconjugates have been proven to be efficient in
inducing T-lymphocyte dependent immunity and to protect both infants as well as elderly from disease. Another approach
to circumvent the T-lymphocyte independent property of polysaccharides is to select peptides mimicking the
immunodominant structures. Several examples of such peptides have been described.

B lymphocytes recognize 5-6 amino acids in case of protein / 4-5 hexose units of polysacc
T lym recognize 10-20 amino acids in length on surface of MHC of APC
TH cells necessary for immunolo memory
So H. inf type b coupled to protein – N. men OMP / diphtheria toxoid
Polysacch capsule vaccines 0f N.men and S.pneu not administered with protein component

43. B

a) aphasia b) ataxic limb movement c) resting tremor d)spastic hemiparesis e)visual field defect
B. ataxic limb movement.

13
first step: which artery is involved? as seen in angiogram this artery arise form proximal portion of basilar artery, so this
is anterior inferior cerebellar artery (AICA).

second step: which structures supply AICA. AICA supplies the caudal lateral pontine tegmentum, and inferior surface of
the cerebellum.

third step: choose from given answer options which is characteristic for cerebellar dysfunction. a, d, e are characteristic
for hemisphere
c. is characteristic for basal ganglia
only b. ataxic limb movements left, which is the correct answer

44 D

The reaction goes from Substrate to Product , S to P

When ∆ G is –, the reaction goes in direction from S to P
When ∆ G is + , the reaction goes from P to S
v-w-x-y-z
the reason being that G0 is spontaneous when it is negative.. these reaxations are reversible. so y-->z is +5.7 so then
z--->y is -5.7 meaning THAT IS THE MOST SPONTANEOUS REACTION and so you would accumulate Y..
if G is negative number reaction goes forward
if G is a positive number reaction cant occur and requires energy
so now from the values given u can easily go from v -w
w-x ,little energy is required
now x will be spontaneously converted to y becoz G is negative
but y-z requires a lot oh energy .......so y will accumulate.

- delta G means that reaction is favorable. More - delta G, more favorable reaction. +delta means that reaction is
unfavourable. More + delta G, more unfavourable the reaction. So, V->W reaction (deltaG -4,0) very favourable, it will
lead to accumulation of large quantitie of product W.
In the presence of large amount of W, second little unfavourable reaction (deltaG +0,4)
W->X will proceed.
X->Z reaction (deltaG -3,5) is also very favourable, and results in accumulation of product Y.
last reaction (deltaG +5,7) very unfavourable. so it would not occur at all.
So correct answer is D. Y will accumulate in the largest amount at equilibrium.

45 A How many fatal recreational cases (1) to all recreational cases( 12 )

Case Fatality is number of deaths/ number of diagnosed patients 1/12

46. D
D Presence of viable sperm in ejaculate. The man must continue to use contraception (such as a condom) until an
examination of his semen reveals that no sperm are present. The disappearance of sperm from the semen is not
detectable by the patient. Only a specific laboratory and microscopic analysis of the semen can verify the total lack of
sperm, which is the goal of the vasectomy surgery.
Vasectomy is a minor surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a
manner such to prevent sperm from entering the seminal stream (ejaculate).
http://en.wikipedia.org/wiki/Vasectomy

14
http://herkules.oulu.fi/isbn9514266641/html/x460.html

47 C
48 C age and typical clinical picture
49 D
50A which goes to the pericardium and create hemopericardium that is why distant heart sounds and diffuse wet
inspiratory cracles
Pain radiates to the back , long history of poorly controlled hypertension
Blood pressure difference on R and L hands

Pseudohypotension (falsely low blood pressure measurement) may occur due to involvement of the brachiocephalic
artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

Early diastolic Aortic regurgitation The murmur is low intensity, high-pitched, best heard over the left sternal border or
over the right second intercostal space, especially if the patient leans forward and holds breath in full expiration. The
radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The
presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the
absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation.

15