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Medicine 2003 WITH Explanation Chandkian
Medicine 2003 WITH Explanation Chandkian
1) Heptoglobin: This is ONE of those MCQs which don’t make any sense but still
you have to select this option. Heptoglobin actually binds to Hb (NOT
Heme) in INTRA-Vascular Hemolysis and is marker of Intra-vascular
hemolysis (will be LOW)
2) Trop-T: After 1 hour NONE of the given marker will be positive (raised). ALL
Cardiac markers tends to be positive AFTER 6-12 hours (some books
say 3-12 h) but Trop-I and Trop-I is somehow superior to others as it
is Cardiac Specific. The value of CK-MB in M.I is that it reaches to Peak
level on 3rd day & then its level decline, so if there is RE-Infarction then it will
help us to diagnose this New Re-infarct.
3) 07mmol/l: The logic is simple= The 7mmol/l is border-line and you should
not be confuse if you have very Low level (Normal Person) OR very High
level (Diabetic) . Confusion is being in b/w.
4) ONLY 2 types of Anemia will give you HYPER-segmented Neutrophil. (1) B12
deficiency (2) Folic Acid deficiency. Only one will give you Neurological
symptoms (Vit B12 deficiency). HYPER Segmented means more than 3-
5 Lobes in more than 5% of Neutrophils OR ONLY one Neutrophil
with 7 lobes.
5) This is too easy! Retro-Strenal will give you shortness of breath on lying
down.
6) Acute Hepatitis B infection = HBsAg +ve, HBeAg HBV DNA +ve and Anti-
HBc-IgM. Carrier (infective) stage of Hepatitis B =HBsAg +ve, HBeAg HBV
DNA +ve, Anti-HBc-IgG. On the other hand Healthy Career = HBsAg +ve,
Anti-HBc-IgG & IgM +ve. Immunized pt serology will be Anti-HBs. Resolving
Hepatitis serology = Anti-HBc-IgG +ve & Anti-HBs +ve.
Remember these pearls: (1) HBsAg is the FIRST MARKER of infection. (2)
HBeAg and HBV DNA are INECTIVE particles (If these are positive then pt is
Highly Infective). (3) Marker of RECENT infection is Anti-HBc-IgM. (4) ONLY
marker that will be present in WINDOW PERIOD is Anti-HBc-IgM.
Now this pt has HBsAg +ve, HBeAg –ve & anti-HBc +ve, which means he has
in RECOVERED (Transient resolving stage of Hepatitis B). It is strongly
recommended that you should understand these serology concepts. For that,
Check First aid for USMLE Step 1 (Microbiology portion) or Goljan Pathology
(Hepato-Biliary and Pancreatic Diseases Chapter).
7) Councilman bodies are characteristic of Apoptosis. Just memorize it. No
Concept
10) ACE inhibitors (Captopril): You know that Diabetics are at risk of
Nephropathy because of Micro-Albumineuria. The only way to prevent this
Micro-Albuminuria is to give ACEi to Diabetic patient. So Captopril is the right
choice.
13) The general rule is: Almost ALL Blood related Hyper-Sensitivity
Reactions are TYPE-II.
16) No concept in this Question. Just remember Mucor for Diabetes (the
same question was given in Feb 2014 Medicine B)
17) Injury in the left 4th intercostals space just lateral to sternum will cause
damage to Intercostals Membrane.
18) To be honest I search out Harrison’s Internal Medicine for Typhoid Lab
Investigations: From there what I got was MASS Confusion. General rule is: In
1st week: Blood Culture. 2nd week Stool Culture BUT according to CPSP it is
Blood Culture + Widal test. In 3rd week: Bone Marrow Culture. Point to
remember is If patient use antibiotic within 5 days prior to Blood culture then
there is good chance that sensitivity of test will be reduced but this is NOT
TRUE for Bone Marrow Culture.
21) General rule is: TSH is the most sensitive test for Thyroid related
diseases (for both Hypo and Hyper).
22) You remember DEXTRO-Cardia? Yes! Heart on RIGHT side. Dextro is for
Right. So D-sugar (Dextro-Sugar) means OH on RIGHT.
23) Middle cerebral artery is the large terminal branch of Internal Carotid
artery. It supplies entire lateral surface of cerebral hemispheres except
superolateral surfaces which is supplied by anterior cerebral artery. (Middle
Cerebral Artery supplies all motor area of cerebral cortex the leg area).
Occlusion of left middle cerebral artery can cause An Aphasia (as in this pt).
24) Posterior auricular artery supplies the Auricle & the scalp.
25) HLA stands for Human Leukocytes Antigen. If we were not wrong and
our teachers didn’t misguide us then Leukocytes is the another name of
White Blood Cells (WBCs). [Question was repeated in Feb 2014 Surgery
paper]
26) This is again a type of MCQs which has info that you’re suppose to
memorize. No concept. DR4 is associated with Rheumatoid Arthritis. HLA-
B27 is for Sero-negative diseases (Like Aknylosing Sponitilitis) etc
27) This is the very definition of Osmotic Diarrhea (gets better with
Fasting).
Osmotic diarrhea: Loss of Hypotonic fluids, No inflammation in mucosa, high-
volume, due to disaccharidase deficiency, “Stunned gut” in Giardiasis.
Secretary diarrhea: Loss of Isotonic fluids, No inflammation in bowel mucosa,
high volume, due to production of Enterotoxicins (in Vibrio Chlera –
stimulates Cl- channels regulated by cAMP & cGMP).
28) RF is for Rheumatoid Arthritis, X-Ray is too non-specific (will not help
you in terms of Pulmonary Embolus) CPK is for muscles related diseases (no
role in P.E) same is true for Ultrasound. The ONLY modality that helps in
terms of pulmonary Embolism is Gallium Scan.
32) This MCQ was also repeated in Feb 2014 Medicine test.
Regarding Transplant Rejection Remember: Both HYPER-acute & Chronic is
Irreversible & ONLY Acute is reversible. Immuno-suppressive therapy will
ONLY effect on T-Cells (will reduce it) and immunity related to T-cells is
CELLULAR. Humoral means Antibodies mediated and it will NOT response to
Immuno-suppressant. So the correct answer is Acute Cellular Rejection.
33) ECG changes with negative Cardiac marker exclude M.I, although
typical question of Pericarditis will be like “patient chest pain relieved on
leaning forward and worsen with bending backward. Pleurisy pain will be
Pleuritic (intensity changes with respiration) and Dissecting Aortic Aneurysm
pain will radiate to back (area b/w scapulae)
34) Winged Scapula is due to the paralysis of Long Thoracic Nerve (that
supplies seratus anterior muscle). Axilllary nerve damage (fracture of
surgical neck of humerus)) will lead to paralysis of Deltoid muscle and loss of
cutaneous sensation over the lower half of deltoid muscle. Accessory nerve
paralysis will leads to Nonfunctional Sternocledonastoid & Trapezius
muscles. The primary clinical manifestation of spinal accessory nerve palsy
is a marked ipsilateral weakness when the shoulders are elevated
(shrugged) against resistance. Median nerve paralysis would lead to Ape’s
Hands deformity. Upper Limb Nerve Injuries (MOST, MOST, MOST important)
If you’re going to study just ONE topic from whole Upper Limb, then that
ONE topic should be Upper Limb Nerve Injuries.
35) Simple solution for this kind of questions: Remember that ONLY TWO
cranial nerves arise from Midbrain (3rd & 4th). FOUR (5th, 6th, 7th & 8th) cranial
nerves arise from Pons. Now this pt has facial paralysis so his Facial nerve
would be damaged. And facial nerve (7th CN) arises from PONS.
38) The same MCQ was also repeated in Feb 2014 Medicine Test. Here
is ONE point you should remember if the question says that patient is on
Gluten FREE diet from 7, 10 days and still have Diarrhea don’t Jump
to Giardiasis (it is still Celiac Disease. Intestinal Mucosa/Villi takes time
to regenerate so even in Celiac disease the Gluten Free Diet will NOT
improve the patient conditions till 2, 3 weeks) BUT if a question didn’t
mentioned the time (like this one) then they are telling you that it is
not Celiac. Whipple’s will also presents with chronic malabsorption
(50%) but along with Diarrhea there will be Neurological symptoms
(30%) as well as Joint pain (80%). Correct answer is Giardiasis.
39) Thiazide Diuretics are one of the minor cause of Acute Pancreatitis is
and once you pick the diagnosis (in this question) then it seem easy to select
Serum Amylase. Epigastric Pain radiating to back and Epigastric tenderness
are the KEY to diagnosis of Acute Pancreatitis. Of NOTE: You know that
Serum Lipase is MORE SPECIFIC than AMYLASE in Pancreatitis. (Just to
refresh your memory)
40) The Key differentiating point b/w Leukemia and Aplastic Anemia is that
In Leukemia Bone Marrow will be HYPER-plastic while in Aplastic Anemia it
will be HYPO-plastic.
41) The Optic nerve fibers terminate in Lateral Geniculate Body (LGB).
Auditory nerve (8th) is related to Medial Geniculate Body while Optic nerve is
to LGB.
43) This is the very definition of X-lined Recessive disease. Before going to
exam hall make sure you know these all definition because CPSP loves to
give 1 or 2 MCQs from these diseases.
44) High urine osmolarity and Low Plasma osmolarity signifies the EXCESS
of ADH which another way of saying SIADH. In Dehydrated patients the Urine
as well as Blood osmolarity (BOTH) will be High. In Diabetes Inspidus and
Mellitus Urine Osmolarity will be Low and Plasma osmolarity will be High.
46) You may select 5% Dextrose but you know what, The FASTEST way to
INCrease blood glucose level is Glucagon. If you don’t have Glucagon in
options then select Dextrose but when Glucagon is there then it will be the
best choice.
49) The Patient is 1 month old and empiric therapy will depend upon
causative organisms (most common pathogen). For below 1 month of age
CDC (Centre of Disease Control) recommendations for Pyogenic Meningitis
are Cefoxitime PLUS Vancomycin PLUS Ampicillin. We avoid Ceftraixone in
infants (till 2months) as there is theoretical risk of Kernicterus. General Rule
is: Above 2 months (and below 60 years) Empiric therapy with Ceftriaxone +
Vancomycin. Below 1 months or above 60 years add Ampicilin as L.
Monocytegenes (one of 4, 5 most common etiological agent in these age
population) intrinsically resistant to ALL Cephalosporins and in below 2
months of age patient replace Ceftraixone with Cefoxitime. I know things are
messed up for you now so let’s clear it with examples.
23 days old patient with meningitis: Treat him with Cefoxitime +
Vancomycin + Ampicillin.
36 days old patient with meningitis: treat him with Cefoxitime +
Vancomycin.
3 months old patient with meningitis: Treat him with Ceftriaxone +
Vancomycin.
40 years old patient with meningitis: treat him Ceftriaxone +
Vancomycin.
67 years old patient with meningitis: Treat him Ceftriaxone +
Vancomycin + Ampicillin.
Remember that above given therapy is empiric you have to change it
according to culture & sensitivity (C&S) once you got the C & S report. This is
what you would do on any exam in the whole world but as you can see there
is no such option so what will you select? Well Pencillin is best option among
them. Empiric therapy means that it will cover maximum suspected
pathogens. Aminoglycosides will cover ONLY gram negative but the S.
pneumonae (gram positive cocci) is leading cause (NOT number ONE) in
neonatal meningitis (most common cause is Streptococcus
agalactiae – group B streptococcus). As we said earlier you can’t use
Ceftriaxone in patient who is less than 2 months of age. Ampicillin is essential
along with Penicillin in this patient but ONLY Ampicillin will not cover most of
the organisms. Cephadrin also has very narrow spectrum. Penicillin is the
best choice in given options.
51) Atrial Fibrillation (A. Fib) means Atria is beating so fast that there is
literally no relaxation phase. When Atria beats that much fast you will NOT
find any P wave on ECG tracing. For P wave to be there on ECG there must
depolarization (contraction) and then repolarization (relaxation) but this
distinction is lost in A Fib.
Bradycardia: well if the question asks what will NOT be related to A. Fib then
select Bradycardia (slow heart rate). In A. Fib heart beats FAST not
SLOW.
P-R prolongation is characteristic of AV block (Heart Block).
Q-wave means OLD Infarct.
S-T segment elevation means Ischemia (related to M.I)
54) Stomach carcinoma has many risk factors like H. Pylori infection,
Smoking, Alcohol & Nitrosamines etc but there is NO evidence that it has
any association with hydrocarbons. In given options ONLY bronchogenic
carcinoma has strong associations with hyrdocarbons.
55) Same MCQ was repeated in Feb 2014 Medicine paper but with
little modification. If question asks (like this one) that GFR is measured
by? Then Select INULIN. If question says “GRF is clinically measured or GFR
in clinical setting measured by? Then select CREATININE. PAH is used for
measurement of Renal Plasma Flow. Inulin is neither reabsorbed nor
secreted in nephron (lumen) so it is ideal for GFR measurement. PAH doesn’t
reabsorbed but secret in some amount inside nephron lumen and ideal for
renal plasma flow measurement. Creatinine is mainly use for measurement
of GRF in clinical setting.
56) Great thing about Great Sephanous vein is that it can be used for
Venesection in states where IV cannulation is a problem (can’t pass IV line).
It is superficial & comparatively big vein. What else I should add to that?
57) M.I pain is severe and patients are anxious so you need to give kind of
pain killer that not only relieve their pain but also reduce their anxiety.
Morphine will do that and additionally it has some VasoDilator effect.
Nitrates and Streptokinase are good in management of M.I but it doesn’t
have any Analgesic effect. Remember question asked about Pain
medication. NSAIDs & Aspirin will reduce pain (additionally aspirin is best in
terms of mortality benefit but again question is about Pain NOT mortality
benefit and aspirin is weak analgesic in regular doses).
59) “Lead II, III, AVF are INFERIOR leads.” So changes in these leads
signify INFERIOR wall M.I. Anterior wall leads = V1-V4. AnteroSeptal leads =
V1-V2, Apical leads are V3-V4. AnteroLateral leads = V4-V6, Lateral leads =
I, aVL.
65) Median nerve has close relation with Supracondyle of Humerus and
fracture of supracondyles can damage median nerve due this close
association.
66) Anatomy: Whenever you have knee injury question and they ask about
ligament that would be expected to injured, Select Anterior cruciate. Anterior
cruciate ligament is WEAKER than posterior cruciate and that’s why injury to
this ligament is more common.
68) Long Thoracic nerve supplies Seratus anterior and its action is to Draw
scapula forward around the chest. When this muscle is compromised (injury
to Long thoracic nerve) person will have hard time to raise arm above the
head and the inferior angle of scapula will be prominent. We call such type
of scapula as Winged scapula.
69) Generally speaking the best initial test for evaluation of iron deficiency
is to look for Red blood cells Distribution Width (RDW) that will be increase.
There are some unique pearls about Fe deficiency that you should
memorize. ONLY microcytic anemia with Increased RDW is Fe
deficiency anemia. ONLY microcytic anemia with Increased Total
Iron Binding Capacity (TIBC) is Fe deficiency anemia. The best
indicator of iron deficiency is to look for Ferritin level (will be Decreased). If
question asks what is the most accurate test for Fe deficiency
anemia? Select Bone Marrow Examination BUT normally we don’t do
that. Serum iron will not be helpful as it can also be decreased in anemia of
Chronic disease, Increase Ferritin (Acute phase reactant) is seen with any
acute infection. Correct answer of this MCQ is Decreased Ferritin.
73) Non-selective proteinuria (> 150mg/24 hr but < 3.5 g/24 hr) : Damage
of Glomerular Basement Membrane (GBM) results in Loss of Albumin &
Globulins i.e Post-Streptococcal Glomerulonephritis.
Selective Proteinuria (>3.5 g/24 hr): Loss of negative charge on GBM with
loss of albumin but NOT globulin, for example Minimal change disease (Lipoid
Nephrosis)
74) Non-keratinizing stratified squamous metaplasia can originate in
Bronchi. Risk factors are smoking, loss of cilia, exposure to dust of different
kinds.
75) Histology: In duodenum there are sub-mucosal Branner’s glands while
in Ileum payer patches are found.
76) In Acute Hepatitis there will be many raised markers like elevated
Bilirubin, Alkaline phosphates but most SPECIFIC one is AST & ALT. AST is
mitochondrial enzyme will be raised more in Alcoholic or Drugs induced
Hepatitis while ALT (cytoplasmic enzyme) will be raised more in viraL
hepatitis, Remember BOTH enzyme will be raised in either types but in drugs
or alcohol related AST level will be much higher and in viraL ALT (compare
to AST) will be raised.
78) BIOPSY is ALWAYS the most accurate test for T.B where on
examination presence of Casaeting Granuloma is Diagnostic of T.B. Many
other granulamatous disease will give you Langerhans cells, Non-caeseting
granuloma.
For ANY Infectious diseases the MOST ACCURATE test will always be the
CULTURE (remember this point)
80) Same MCQ with little modifications repeated in Feb 2014 Medicine
Paper. Major Opsonin are IgG (Fc fragment) and C3b. In Feb 2014 they
asked the same question but in correct choice ONLY C3b was given (No IgG
was there in any option). Opsonin function is to bind bacteria with
Neutrophil and this job is done by C3b along with IgG.
Major point is: before entering to exam hall make sure you memorize Major
Opsonin, Chemotactic agents (C5a, LTB4 & IL-8), Anaphylatoxin (C3a & C5a),
Ca5 also activate Neutrophil adhesion molecule.
81) MCV of 116 fL is another way of saying Megaloblastic anemia. You can
easily recall from your Pharmacology concept/knowledge that Methotrexate
causes Folic Acid deficiency so it must be the causative agent in this lady.
Gold, Chloroquine (especially in G6PD deficiency pts), Pencillamine can
cause hemolytic anemia. Doxorubicin is notorious for Cardio-toxicity but
none of them will cause Megaloblastic anemia (with MCV 116) except
Methotrexate.
82) While dealing with such kinds of questions search out two things.
Patient is pregnant? After how much time she died? If time is NOT given (like
this question) then go for Amniotic Fluid Embolism but if time is given
(suppose after 60 hr of accident pregnant patient died) then they are telling
you that DON’T select Amniotic fluid embolism instead go with Fat
embolism.
Remember that in amniotic fluid embolism pt will show symptoms short after
accident (within hours NOT days). Correct answer of this MCQ is Amniotic
fluid embolism.
85) FEV1 of 50% with Cyanosis means that pt is NOT getting enough
Oxygenation so the best initial management will be to give him Oxygen.
Giving him Steroids (IV or Inhalational) or bronchodilators will NOT help him.
These 3 modalities are mainly used for Bronchospasm (to relieve it) and
problem with brochospasm pts is NOT getting enough O2 but to get rid of
CO2 (Expiration is problem NOT Inspiration). This pt has Inspiration problem
NOT expiration. Antibiotics will NOT help him as he needs emergency
management and antibiotics will take time to show its action and other thing
is that we don’t know what is the etiology of this pt current problem? If it is
NOT infectious then antibiotics will be of no value EVEN in long run.
88) Posterior part of Posterior limb carries corticospinal fibers and damage
to this portion will cause motor weakness without sensory loss.
89) 3rd & 4th from Mid-Brain and 5th to 8th from Pons.
90) She has A +ve blood group so logically she must receive blood from A
+ve.
93) Chest pain that is NOT pleuratic (Not change with respiration) is most
likely to be Cardiac origin (Myocarditis). ALL others given options pain will
change with respiration.
98) History of mishandled labor & Now Fever & prolonged PT + aPTT with
Low TLC is equal to D.I.C. Whenever you have labor in question think of 3
main things (1) Sheehan’s Syndrome (pituitary apoplexy – sudden onset of
neurologic dysfunction due to postpartum necrosis) (2) Amniotic fluid
embolism (there will be Hx of trauma) (3) DIC. In DIC Look for: Elevation of
BOTH PT and aPTT, Low platelet count, Elevated d-dimer and fibrin split
products & Decreased fibrinogen level (it has been consumed).
All others 3 options (Hemorrhagic shock, Septic shock & Uterine rupture) by
itself will NOT give you prolong PT & aPTT but they can lead to DIC. Correct
answer is DIC
102) Ascending from depth (rapidly) causes Caisen diease (also called
bending) and the pathogenesis of this disease is that N2 dissolved in blood
vessels (in deep sea) when a person ascend quickly to the surface the
dissolved N2 produce bubbles in arteries. Main symptom of Caisen disease is
Seizures.
103) The idea behind this question is do you what type of Necrosis does
occur in brain tissue? You know that! Liquefactive Necrosis. Coagulative
type of necrosis occurs in heart, kidney etc etc… Karhyexis & Karyolysis are
the feature of Apoptosis NOT necrosis.
107) Read the question carefully: after injury pt can’t move the leg
ANTERIORLY, on exam Tibia is displaced ANTERIORLY. Recall what we said
earlier ANTERIOR ligament is WEAK. So with these three ANTERIOR words
answer to this question must be Anterior cruciate ligament injury. Again if
they give you a question of Knee ligaments injury then more than 90%
chances are that correct answer will be ANTERIOR cruciate ligament.
110) Most of fat absorption takes place in ileum and after ileostomy the
absorption area will be compromised. As result there will be loss of fats.
114) Dialysis is done to remove excess of waste & harmful substances from
the body and its basic principle is on Osmosis. Chronic Renal Failure Pts will
have High K+ & Urea while Low HCO3. To maintain normal homeostasis you
will need LOW Potassium, Urea & High Bicarbonate in Dialysis fluid.
Generally K, Urea are in LOW concentration (than plasma) and HCO3,
Glucose are in HIGHER concentration. Ca++, Mg+, Na+ are almost equal to
plasma concentration. As result the excess of K+ and Urea will excrete (from
plasma) and HCO3 & glucose will absorb (into plasma).
116) Night blindness is the first sign of Vit A deficiency and other
manifestations of Vit A deficiency include Keratitis, Metaplasia, Bitot spot
(Keratomalacia, Xerophthalmia) etc. Aphtous ulcer is idiopathic condition
and has NO known association with any nutritional deficiency. Bleeding
gums (scurvy) & Gingivitis is due to Vit C deficiency. Cheliosis is due to
Riboflavin (Vit B2) deficiency.
117) All given options will add to T.B diagnosis but you can see the question
asked about definite diagnostic feature/test that is Casaeous Necrosis. Giant
cells & Epitheloid cells are present in many granulomatous infections.
Montoux test will ONLY helpful in term of screening (will tell us is there any
prior exposure? And positive test is NOT 100% diagnostic of current
infection). X-ray chest and all other Radiological tests would NEVER be the
most accurate test for any infectious disease. As we said earlier the MOST
Accurate test will always be BIOPSY/CULTURE (in this case Caseous
Necrosis).
120) This pt has raised Direct Bilirubin & Alkaline phosphatase level. Her
SGPT (AST) level is normal. Viral & Alcohol hepatitis will NOT presents with
normal AST/ALT level (both will be elevated). Given pt labs are telling us that
her problem is outside the liver architecture (normal SGPT) but inside
hepato-billiary system (raised alkaline phosphatase & Direct Bilirubin). So
the correct answer is Extrahepatic Billiary Obstruction.
121) IL-3 is secreted by T-cells and supports the growth & differentiation of
Bone Marrow Stem cells. Functions Like GM-CSF (Granulocytes Monocytes-
Colony Stimulating Factor). [Reference: First Aid for USMLE step 1-
Immunology]
125) This pt has Acute Renal Failure (ARF) and he has HYPOkalemia &
HYPOnatremia. You have to give him something that will NOT ONLY correct
his HYPOnatremia but also his LOW K+ and for that purpose the best option
is to give him 0.9% NaCl + Potassium. Giving him 5% D/W & Insulin is like
shooting him in the skull. Insulin will drive K+ into the cells and will worsen
his HYPOkalemia. Diuretics will NOT help him. In fact it may worsen his
HYPOkalemia (Except K+ sparing Diuretics). Giving him Fresh Frozen Plasma
is like giving chocolate to a girl who is dying of thirst (Will NOT be helpful).
5% D/W is good for mild to moderate dehydrated pt with Normal K+ & Na+
level but this pt is NOT a good candidate for such kind of luxury fluid. Give
him Normal Saline with Potassium – That’s all!
126) History of sore-throat and now presented with blood in urine. You will
easily diagnose him as case of Post-streptococcal Glomerulonephritis. No Big
Deal!
127) It is simple! Chronic Epigastric pain (Ulcer) now presented with Cervical
Lymphadenopathy (Virchow Node) and biopsy report revealed Lymphoma.
They are telling you that Please select H. Pylori (Nasty bug that causes
Peptic ulcer and 4% of Gastric – NOT DUODENAL ULCER – ulcer can
transform into malignancy and it is strongly associated with Lymphoma –
MALToma)
128) Staging – Hate it. When metastasis do occur from Colorectal carcinoma
to Liver, Kidney = Stage IV. Now we have two options with stage IV (IV-A &
IV-B) so which one is correct? After searching Robbin’s Pathology, Current
Diagnosis and Treatment in Gastroenterology, Hepatology & Endoscopy and
Harrison’s Principles of Internal Medicine I came to know that THERE IS NO
STAGE IV-A or IV-B. ONLY STAGE IV. The correct answer to this question is
Stage IV-A. By the way staging of Colorectal carcinoma is done by DUKE’s
staging system & well-known TNM classification method.
129) Again this is type of MCQ which is directly related to the simple fact
“How much you remembered your pathology” Mallory bodies are the
characteristic of Alcoholic Hepatitis. I remembered Alcoholic related
abnormalities like this “In Liver it will give Mallory bodies while In Brain
Mamalliry Bodies will be effected in Alcohol related Wernicke-Korsakoff’s
Syndrome – secondary to Thiamine (Vit B1) deficiency.
132) Axillary nerve arises from the POSTERIOR CORD of brachial plexus and
supplies deltoid muscle as well as skin over Lower half of deltoid. (Upper half
skin supply is from Supraclavicular nerves).
135) Remember this Pearl: Any pt with age > 50 years, presented
with PR (per rectal) bleeding or constitutional symptoms (weight
loss, fatigue etc) and microcytic (Fe deficiency) anemia = Colorectal
Carcinoma.
136) While reading this question carefully separate: (1) 20 years old (Young)
Female, (2) Fever, (3) Irregular movements of limbs, head & neck (Chorea –
to be specific Syenham’s Chorea) and (4) Subcutaneous nodule. Now you
can diagnosis of this pt (Rheumatic Fever). In given options ONLY ASO titer
will help us in terms of her diagnosis.ASO titer is for beta-hemolytic
Streptococci.
141) Nasal deformity + Acid Fast Bacilli = Leprosy. If the question says
“granuloma, nasal deformity, hematuria and positive c-ANCA” then they are
telling you that please select Wegner’s Disease. BUT when question is
crystal clear like this one then select Leprosy with Eye Closed.
142) Hypoxia will lead to activate Erythropoietin which will in turn stimulate
Erythropoiesis. WITHOUT HYPOXIA NO ACTIVATION of Erythropoietin. So
don’t get confuse that which one is the stimulus for Erythropoiesis? It is
Hypoxia. If you don’t have that (Hypoxia) stimulus Erythropoietin (EPO) is
NEVER going to increase RBC production.
For example after living on normal sea level for many decades you shifted to
high altitude then your erythropoiesis will boost up. Don’t tell me that it will
be because of your Erythropoietin (you have these Kidney & EPO for decades
then why now they came into action?). Something is change with your
current journey. Yes Oxygen tension and now you have HYPOXIA and this
hypoxia activated your Kidney (EPO) which then in turn boosts up your
Erythropoiesis.
143) Colon (Large Intestine) is the major site of K+ secretion and after
Colostomy a portion of Colon will not be available for this job (K+ level will
be increased). So normally we advise these pts to utilize minimum amount
of (restrict) K+. If pts don’t follow the instruction (like one in given question)
then they will have HIGH K+ level. The idea behind this question is “Do you
know where in GI tract, maximum amount of Potassium is secreted?” So tell
them “Yes! I know K+ from Kolon (Colon).”
145) Position & Vibration sensations enter the spinal cord in the Dorsal gray
column and ascend in Dorsal-Medial Leminiscus System.
150) Bluish color red mass one face in young children is Most likely to be
Capillary Hemangioma. These lesions regress spontaneously.
152) The right sequence of body fuel is “Carbohydrate 1 st then Fat and lastly
Protein.” In Feb 2014 question was given that after 48 hours fasting what
will be the major fuel for body metabolism? Options were (A) Muscle
Glycogen (B) Liver Glycogen (C) Protein (D) Fatty Acids (E) Triglycerides. It is
recommended that you should carefully read and understand this topic in
USMLE first aid (Biochemistry portion). General sequence is that initially
Liver Glycogen will be utilized in Fasting state after that Muscle Glycogen.
Body stored (Both muscle as well as liver) Glycogen are utilized within 24
hours (and it is almost impossible to stay at Glycogen after 48 hours). After
Glycogen the main fuel for body will be Fat. Protein will be utilized at the
end.
153) This MCQ was repeated in Feb 2014 Medicine Paper B. Oral
anticoagulant therapy is just another way of saying Warfarin. Monitoring of
Warfarin is done by Prothrombin Time (PT) and monitoring of Heparin is done
by activated Partial Thromboplastin Time (aPTT). Kindly memorize these two.
CPSP loves this topic. One way to remember Warfarin PT and Extrinsic
pathway: Ex-PresidenT went for Warfare.
Just to repeat it & clarify ONE minor point: Whether the pt is antigoagulated
with with Heparin or Warfarin, BOTH PT & aPTT are prolonged, because
BOTH inhibit factors in Common Final Pathway. Experience has shown
that PT performs better in monitoring Warfarin, while aPTT performs
better in monitoring Heparin.
154) As we discussed earlier in Amniotic fluid embolism question, the critical
thing in Embolism question is TIMING. This pt has femur fracture and
developed symptoms after 24 hours. They are simply telling you that please
select Fat embolism. Thrombo-embolism symptoms will be sudden in onset
and there will be risk factors in question stem. If answer to this question was
Thrombo-embolism then question would be like this. “Pt was operated for
femur fracture 1 week back, he was not mobilized since operation and now
presented with shortness of breath and chest pain.” CPSP loves Embolism
questions. We will go in further details accordingly. Lets move forward for
the time being.
156) Carcinoma of Liver (Hepatoma) with Ascites & peripheral Edema are
the signs of Portal Vein Obstruction. Hepatoma, Cirrhosis all mean Liver is
NOT working and when Liver is out of order Portal Vein will have hard time to
do his job that will produce Portal Hypertension. Inferior Vena Cava
Obstruction can give you ascites & peripheral edema but question already
gave us the pt diagnosis (Hepatoma). Budd-Chiari Syndrome is rare
condition of Hepatic Vein occlusion that can presents with classical triad of
Abdominal Pain + Ascites + Hepatomegaly.
Bottom line is this pt Portal vein obstruction (secondary to Liver Carcinoma)
is the main culprit of Ascites and Edema.
157) Smoker lungs: there will be Decreased number of cilia, Increased (NOT
decreased) number of Goblet cells, Mucosal Hypertrophy (NOT atrophy),
Decreased (NOT increased) number of submucosal glands. So the correct
answer is Decreased number of cilia.
161) A lot of confusion regarding this MCQ. Before your first attempt your
seniors will tell you “many CPSP questions don’t make any sense.” Actually it
is NOT correct. All these questions that you have in MCQs books are just
what candidates recall after their test. In reality more than 95% questions
will be crystal clear. You will get it on first read (although you can debate on
quality of question but you can’t say question was confusion in maximum
cases). The ONLY problem with CPSP questions (less than 5%) is that it will
be from that area which will be NOT clear to anyone till that date. Many
other professional examinations around the world avoid such questions
(controversial area). For instance USMLE will never ask this question with
given options. They will clearly test your knowledge NOT how tricky you are.
If this question was given by USMLE then they will go you either Bronchgenic
Carcinoma OR Mesothelioma but NOT BOTH Options for a single question
with such a confusing description. Now lets move to the answer: MOST
COMMON Cancer & MOST COMMON Cancer KILLER is Bronchogenic
Carcinoma. You also know that exposure to Asbestoses can increase the risk
of Bronchogenic Carcinoma 70 times. From this discussion you will say “Ok!
So we should select Bronchogenic carcinoma as an answer”. NO! Don’t do
that. Mesothelioma is also highly associated with Asbestoses. General rule is:
If question stem have smoker as well as Asbestoses then select
Bronchogenic Carcinoma BUT if they simply ask regarding asbestoses
association with type of cancer (Like this question) OR in question where pt
is Non-smoker then select Mesothelioma.
162) You will say “That must be Occulomotor plasy as you said earlier that
Diabetics are at risk of 3rd cranial nerve palsy” yes! They are but kindly read
the question again and extract just two things out of it. (1) Drooping of
eyelid. (2) Small pupil – Meiosis. Now recall what we said about Horner
Syndrome? In Horner Syndrome there will be (1) Ptosis (drooping of eyelid.
(2) Meiosis- small pupil.(3) Anhydrosis (loss of sweating) of that side. BUT we
have ONLY two of them then how come it will be Horner? Seriously! If you
have all the three features in questions then who will NOT diagnose this
case? By the way in that (previous question of Occulomotor plasy) pt Pupils
were dilated NOT constricted. Bottom Line is “Horner Syndrome is the
correct answer to this question.”
163) The most common arteries that involved in Pulmonary Embolism are
Medium sized pulmonary arteries. This is factual question and you can’t
explain it further.
164) ADP + PiATP. If we are not wrong, in this process ATP is synthesized!
So enzyme which catalyzes this reaction must be called something
synthetic. Yes ATP Synthase. I memorized this enzyme the way I explained.
Don’t know what else I should do, to make it simple.
167) Amylase is from Sliva & Pancreatic Juices, Lactase is from small
intestine submucosal glands, Trypsin is active form of Trypsinogen which is
secreted by Pancreas and then converted into Trypsin in duodenum by
Enteropeptidase. So the correct answer is Enterokinase.
168) From your basic knowledge of general pathology you will jump into
Coagulative Necrosis because you studied that Coagulative necrosis is seen
in Kidney, Heart & Liver etc. But just re-read the question. Question says
distorted area, epitheliod cells, lymphocytes & giant cells. If you can recall
these all are the features of what? Yes! Casaeting Necrosis! But it is LIVER
how come in Liver? Well! It is not unusual for Granuloma to be formed inside
Liver. Caseous Necrosis is a variant of Coagulative Necrosis. This question is
repeated many times in past few years. So make sure that you clarify your
concept regarding Liver, Coagulative & Caseous Necrosis. Presence of
Epitheliod cells, lymphocytes and giant cells is equal to Caseous
Necrosis EVEN if they give you that presentation inside Brain, Liver, Kidney
(Irrespective to the site/tissue of granuloma).
169) Normal IgA level Excluded IgA deficiency (B-cell disorder). These pts
are at risk of Anaphylaxis if exposed to blood products that contain IgA.
SCID stands for Severe Combined Immunodeficiency Disease – an
autosomal recessive disorder (Combined B & T cells disorder). Bruton’s
Agammaglobulinemia (Opsonization defect) is a B-cell disorder in which
pts are at risk of SinoPlumonary infections. They will be fine till 6 months (as
maternal antibodies are present up to 6 months) after that these pts start
showing symptoms. Di George syndrome (T-cells disorder) is due to
Failure of 3rd & 4th pharyngeal pouches to develop and as result No Thymus
& parathyroid glands development.. Clinical features of DiGeorge syndrome
are: Hypothyroidism (tetany) absent thymic shadow on X-ray. These pts are
at risk of Graft vs Host reaction. Wiskott-Aldrich syndrome is combined B
& T cells X-linked recessive disorder whose symptom triad is: Eczema,
Thrombocytopenia, SinoPulmonary Infections. These pts have LOW IgM,
HIGH IgA & IgE and NORMAL IgG. So the correct answer to this question is
Wiskott - Aldrich syndrome.
I know you will feel exhausted and for your ease I will suggest please ignore
everything in above explanation and just remember these: While transfusing
blood to IgA deficient pt, use IgA deficient blood. DiGeorge syndrome
is due to failure of 3rd & 4th pouches development & No Thymic
Shadow on X-ray. Wiskott – Aldrich syndrome: pts with present with
Eczema + recurrent chest infection & Thrombocytopenia. That’s all!
170) Kawasaki disease is already discussed along with Poly Arteritis Nodusa
(PAN) in MCQ 166. The correct answer is Kawasaki disease. Now few words
about Buerger’s disease or Thromboangitis Obliteran & Takayasu arteritis Or
Pulseless disease. Buerger’s disease is EXCLUSIVELY a disease of SMOKERS.
It is medium-sized vessel vasculitis with digital thrombosis. Clinical features
include Resting pain on the forefoot with possible ischemic ulcer or gangrene
& Reynaud’s phenomenon. Treatment is SMOKING cessation & IV
prostacyclin analogue (iloprost). Takayasu disease is the granulomatous
large vessel vasculitis involving Aortic arch vessel. It is more common in
Asian women & children. Clinical features include: Absent upper extremities
pulse, discrepancy in blood pressure b/w arms > 10 mmHg, visual defects
and sometimes stroke. It is generally treated with Corticosteroids. Again you
may think why that much details? Well you can ignore all the above
explanation BUT you have to remember these two points: (1) Buerger’s is
a Disease of Smokers that will ONLY be effectively treated with Smoking
cessation. (2) Young Asian female + Diminished pulses = Takayasu's
arteritis.
171) Remember this; Young woman (20-40 yrs old) with Tight Skin +
Heartburn + Raynaud's phenomenon = Scleroderma.
Scleroderma or Progressive Systemic Sclerosis is disease of Unknown
etiology. Scleroderma is diffuse in 20% of cases and limited in 80%. Limited
scleroderma is also known as CREST syndrome (Calcinosis, Raynaud,
Esophageal dysmotility, Sclerodactyly, Telangiectasia).
Regarding diagnostic testing: There is no single diagnostic test. ANA is
present in 95 percent of cases but is nonspecific. Antitopoisomerase (anti-
Sci 70) is only present in 30 percent of patients. Anticentromere
antibodies are extremely specific for CREST syndrome.
Lungs Fibrosis and pulmonary hypertension (these are the leading cause of
death) in Systemic Sclerosis.
SLE, Poly Arteritis Nodusa & Serum Sickness will NOT presents with Dsyphgia
& Dysarthria. This pt gender and symptoms are consistent with Systemic
Sclerosis. Yes! SLE is common is also common is females but as I said it will
NOT give you Difficulty in swallowing and difficulty in speech. It will classically
presents with Rash (Butterfly rash) Joint pain, Photosensitivity and Oral Ulcer,
Fatigue etc.
172) Effects of Glucagon are: (1) Break down of Glycogen (Glycogenolysis) &
Production of New glucose (Gluconeogenesis). (2) Break-down of Lipids
(Lipolysis) & Ketone production. (3) Inhibition of Insulin. Additionally its
secretion is increased in starvation so that more & more glucose are produce
for energy utilization. In given question all other options are correct except
the one which say “It is Non ketogenic” because Glucagon IS KETOGENIC.
173) An antibody with highest concentration in serum is IgG. Below are the
some unique characteristics of each antibody:
(1) IgG = Smallest (in size) antibody, Highest concentration in serum, One
that crosses placenta and antibody that is known as a Warm antibody.
(2) IgM = Largest in size, antibody that is mainly Intravascular, Earliest
antibody to be synthesized and Cold antibody.
(3) IgE = Reagenic antibody, antibody with Minimum life, Heat labile
antibody.
(4) IgA = Antibody that protect surfaces, antibody that is present in body
fluids like Saliva, Breast Milk
174) Women are Fatty compare to men. Their muscles have larger fat
content than men. In ALL other parameters (Power, Strength, Endurance &
Myoglobin) male muscles are Superior than female muscles.
NOTE: File was uploaded in bit hurry. Explanation to some questions will be
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of explanation for other past paper)
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