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You are on page 1/ 79

2 VOLUME SET

PART – A

SUBJECTS COVERED

ANATOMY PREVENTIVE AND SOCIAL MEDICINE (PSM)


01 Dr Shrikant Verma
04 Dr Mukhmohit Singh

PHARMACOLOGY OTOLARYNGOLOGY
02 Dr Ranjan Kumar Patel
05 Dr Rajiv Dhawan

PATHOLOGY OPHTHALMOLOGY
03 Dr Preeti Sharma
06 Dr Utsav Bansal

EDITED BY

Dr Sudhir Kumar Singh

CBS Publishers & Distributors Pvt Ltd


• New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai
• Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand
Preface

Success is not final; failure is not fatal: it is the courage to continue that counts.
—Winston Churchill

We are immensely pleased to write the Preface to this book which is one of its kind. The idea to introduce this student-friendly and exam-oriented book
sprouted after doing intensive market research and interactions with students who encouraged us to bring our nascent idea into a proper shape and today
it is in your hand in the form of this illustrious book.
This book is the result of not one or two rather it is the amalgamation of ten medical scholars’ experience and knowledge and for this, we all are
heartily indebted to CBS Publishers and Distributors who have not only turned our dream into reality but also added another feather to their cap in the
form of this charismatic achievement.
Now let us discuss something about this book. As the name suggests, this wonderful and amazingly designed book is meant for NEET/INI-CET/
NExT/FMGE aspirants. This meticulously written and sensible arranged book compiles more than 10,000 questions covering 10 subjects. Conceived
and formulated by ten distinguished and highly reputed medical scholars, this book covers Multiple Choice Questions extracted from all the
sought-after topics with their authentic and to-the-point answers. The icing on the cake is inclusion of duly updated references and one-two liners
explanations of the important questions. We have not stopped here but kept adding value to the book by inserting useful tables along with recent
advances in the form of brief theory of respective subjects.
Now, let us understand the structure of the book. The overall Question Bank has been divided into three categories:
1. Last Five Years NEET and INI-CET Recall
2. Frequently-asked Questions
3. Newly-created Clinical-based Questions
Keeping this categorization in mind, we are pretty sure that this book will prove a panacea for all the woes of the students. It is the answer of all their
queries which had been haunting their minds before the arrival of this book.
As the motto of this book is: Practice, Practice and Practice, your regular practice and honest efforts will make your dream true and this book is
Brahmashtra which never misses its target. It will prove your true companion and guide you toward success for sure.
With the hope that this book, which is the outcome of Ten distinguished authors’ relentless efforts, will hit the bull’s-eye for you, we are wishing best
of luck to our students for their future endeavors.
Always remember this: “Believe you can and you’re halfway there.”

—Authors
Acknowledgments

We express our sincere thanks to The God Almighty, for giving an idea to accomplish this book. We express our heartiest gratitude to our family
members for their unconditional support and motivation to fulfil this commitment.
We would like to thank Mr Satish Kumar Jain (Chairman) and Mr Varun Jain (Managing Director), M/s CBS Publishers and Distributors
Pvt Ltd for providing us the platform in bringing out the book. We have no words to describe the role, efforts, inputs and initiatives undertaken by
Mr Bhupesh Aarora, Sr. Vice President – Publishing and Marketing (Health Sciences Division) for helping and motivating us.
We sincerely thank the entire CBS team for bringing out the book with utmost care and attractive presentation. We would like to thank
Ms Nitasha Arora (Assistant General Manager Publishing – PGMEE & Nursing Division), Ms Daljeet Kaur (Assistant Publishing Manager)
and Dr Anju Dhir (Sr. Product Manager and Medical Development Editor) for their publishing support. We would also extend our thanks to
Mr Shivendu Bhushan Pandey (Sr. Manager and Team Lead), Ms Surbhi Gupta (Sr. English Editor), Mr Ashutosh Pathak (Sr. Proofreader cum
Team Coordinator) and all the production team members for devoting laborious hours in designing and typesetting the book.
Special Features of the Book
From the Publisher’s Desk

Dear Students,
Let us begin with a power-packed and inspiring quote:
Arise, awake, and stop not until the goal is achieved.
—Swami Vivekananda
Healthcare is undoubtedly one of the most noble and sacred professions. We are truly fortunate to be a part of this
field, which stands as a beacon of selfless service to humanity. Healthcare professionals work tirelessly, transcending
boundaries of caste, creed, religion, community, nationality, and preferences. Their service is a testament to the divine
nature of this profession.
We extend our deepest gratitude to all healthcare professionals for their unwavering commitment, particularly during the pandemic. When the world
retreated behind closed doors, these brave individuals stood on the frontlines, leaving no stone unturned in saving the lives of people.
At CBS Publishers, we take great pride in supporting the healthcare community by offering resources that empower future professionals. Nine
years ago, we laid the foundation in the PGMEE segment with titles such as the Conceptual Review Series, SARP Series, AIIMS MedEasy, NIMHANS,
PGI Chandigarh, My PGMEE Notes, ROAMS, PRIMES, FMGE Solutions and many more.
What makes our PGMEE books stand out is the updated, simple, clear, and easy-to-understand language, making study sessions feel less like a
challenge and more like an enjoyable learning experience. A team of our esteemed medical educators brings their expertise to create these comprehensive
yet compact books, ensuring that all the critical topics are covered.
A special feature of our books is the use of illustrations that simplify complex concepts, making them easier to grasp. We also include previous years’
questions, complete with detailed explanations, which are invaluable for exam preparation. Image-Based Questions (IBQs) further enhance the learning
experience. The combination of concise theory and multiple-choice questions makes these books the ultimate tool to ease exam-related worries.
FMGE Solutions is one of our best-selling titles, meticulously designed to meet the specific needs of FMG aspirants. This comprehensive guide is an
all-in-one resource for FMGE preparation, offering in-depth coverage of essential topics, detailed explanations, and a wide array of questions that reflect
the latest exam patterns. Its reputation as a bestseller speaks to its effectiveness and reliability as a trusted resource for future medical professionals.
One Touch Series, is tailored specifically for aspirants of NEET PG, NExT, FMGE, and INI-CET. Conceptualized with a focus on last-minute revision,
the One Touch Series covers a complete range of preclinical, paraclinical, and clinical subjects. These concise, expertly curated books are designed to help
students efficiently review key concepts, ensuring they are well-prepared and confident as they approach their exams.
This year, we are introducing a new addition to the CBS Exam Book Series: Ten into Ten (Part A and B). According to the market research, there was a
gap, and at present no book is available for practice. Although there are multiple apps from where students can attempt test series, for offline practice, no
single update book is available in the market to fill this gap. The motto of this book is Practice: Practice: Practice as this book offers a decent amount of
MCQs which will meet the evolving needs of students. Ten into Ten is a comprehensive question bank covering 19 medical subjects. It offers over 10,000
meticulously curated questions across 10 key subjects, crafted by 10 renowned medical scholars.
Following this, we will soon release the next part, Nine into Nine, further expanding our collection of practice materials for the PGME Examination,
with the latest and most effective study approaches.
At CBS, we are committed to revolutionize the medical education and your support and encouragement can make our task easier. So, keep extending
your support by sending your feedback to us. We will be highly pleased to serve you and make you victorious in your career. You can share your feedback
at [email protected]
Wishing you all the best in your endeavors.

Mr Bhupesh Aarora
(Sr Vice President – Publishing & Marketing)
[email protected]| +91 95553 53330
Contents

Preface ............................................................................................................................................................................................................................................... iii


Acknowledgments ............................................................................................................................................................................................................................. iv
Special Features of the Book .............................................................................................................................................................................................................. v
Detailed Table of Contents ........................................................................................................................................................................................................ xi–xiv
[Subject-wise cum Topic-wise Questions]
Most Recent Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� xv–lix
[NEET PG 2024 and INI-CET MAY 2024]

ANATOMY  1–213
Dr Shrikant Verma
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1–50
Multiple Choice Questions ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 51–213

PHARMACOLOGY  215–325
Dr Ranjan Kumar Patel
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 215–229
Multiple Choice Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 231–325

PATHOLOGY  327–482
Dr Preeti Sharma
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 327–353
Multiple Choice Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 355–482

PREVENTIVE AND SOCIAL MEDICINE (PSM)  483–645


Dr Mukhmohit Singh
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 483–500
Multiple Choice Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 501–645

OTOLARYNGOLOGY  647–761
Dr Rajiv Dhawan
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 647–666
Multiple Choice Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 667–761

OPHTHALMOLOGY  763–932
Dr Utsav Bansal
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 763–808
Multiple Choice Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 811–932
Detailed Table of Contents
[Subject-wise cum Topic-wise Questions]

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

ANATOMY

1. General Anatomy 2 51 18 71

2. Histology 17 31 15 63

3. Embryology 17 96 20 133

4. Upper Limb 14 104 31 149

5. Lower Limb 11 80 32 123

6. Thorax 3 66 16 85

7. Abdomen and Pelvis 24 120 29 173

8. Head and Neck 26 77 19 122

9. Neuroanatomy and Back 32 54 22 108

Total Qs 146 679 202 1027

PHARMACOLOGY

1. General Pharmacology 22 42 15 79

2. Clinical Pharmacology 0 21 0 21

3. Autonomic Nervous System 10 77 15 102

4. Cardiovascular System 12 81 14 107

5. Kidney 4 22 5 31

6. Central Nervous System 41 77 15 133

7. Antimicrobial Drugs 30 168 30 228

8. Anticancer Drugs 11 37 15 63

9. Endocrinology 11 54 15 80

10. Autocoids and Immunomodulators 15 47 6 68

11. Respiratory system 4 12 4 20

12. Gastrointestinal system 5 26 6 37

13. Blood 10 23 9 42

Total Qs 175 687 149 1011


xii Detailed Table of Contents

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

PATHOLOGY

1. General Pathology 69 108 116 293

Cell Injury 16 19 23 58

Inflammation and Thromboembolism 11 28 14 53

Neoplasia 14 16 27 57

Immunity 17 27 33 77

Genetic Disorder 11 18 19 48

2. Systemic Pathology 54 84 208 346

Cardiovascular System 10 5 26 41

Respiratory System 7 7 14 28

Gastrointestinal System 6 10 23 39

Liver, GB, Pancreas 1 3 19 23

Renal System 7 11 35 53

Central Nervous System 3 9 18 30

Endocrinology 1 10 14 25

Male and Female Genital System 8 3 35 46

Breast 3 5 10 18

Skin and Related Disorders 4 4 5 13

Diseases of Muscles 0 2 1 3

Bone 2 2 6 10

Tumors of Soft Tissue, Head and Neck 2 13 2 17

3. Hematology 43 35 125 203

Red Blood Cells 14 10 42 66


Detailed Table of Contents

White Blood Cell 19 16 58 93

Platelet and Bleeding Disorders 5 4 19 28

Vacutainers and Instruments 5 5 6 16

4. Blood Banking And Transfusion Medicine 6 17 6 29

Total Qs 172 244 455 871


TEN into TEN xiii

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

PREVENTIVE AND SOCIAL MEDICINE (PSM)

1. Medical Research 56 151 15 222

Principles of Epidemiology 22 37 13 72

Principles of Screening for Disease 7 31 1 39

Biostatistics 27 83 1 111

2. Public Health 123 268 121 512

Demography and Family Planning 9 35 19 63

Preventive Obstetrics 11 15 4 30

Preventive Pediatrics 5 27 12 44

Immunization and Vaccines 10 38 10 58

Communicable Diseases and Related National 42 39 53 134


Health Programs

Noncommunicable Diseases and Related 14 36 5 55


National Health Programs

Health Planning and Healthcare Management 12 25 8 45

Hospital Waste Management 8 21 2 31

Health Education and Communication 2 7 5 14

International Health Agencies 2 14 0 16

Disaster Management 8 11 3 22

3. Preventive Medicine 53 241 36 330

Evolution and Concepts in Community 11 38 0 49


Medicine

Basis of Infectious Diseases 3 38 0 41

Nutrition and Related National Health 21 46 1 68


Programs

Detailed Table of Contents


Environment and Related National Health 8 77 23 108
Programs

Occupational Health 6 22 8 36

Social Science and Health 3 13 4 20

Mental Health and Genetics 1 7 0 8

Total Qs 232 660 172 1064


xiv Detailed Table of Contents

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

OTOLARYNGOLOGY
1. Ear 36 258 43 337

2. Nose 26 118 25 169

3. Oral Cavity and Pharnyx 16 100 11 127

4. Larynx 12 129 26 167

Total Qs 90 605 105 800

OPHTHALMOLOGY
1. Anatomy and Physiology of Eye 1 0 4 5

2. Optics 11 16 13 40

3. Strabismus 9 26 7 42

4. Neuro-Ophthalmology 14 28 14 56

5. Lens 7 42 9 58

6. Glaucoma 14 29 8 51

7. Uvea 5 21 5 31

8. Retina 12 62 27 101

9. Lacrimal Apparatus 4 12 3 19

10. Orbit and Eyelids 10 24 9 43

11. Trauma 5 14 2 21

12. Conjunctiva 8 22 4 34

13. Cornea 10 26 8 44

14. Community Ophthalmology 1 4 2 7

15. Miscellaneous 1 0 0 1

Total Qs 112 326 115 553

MOST RECENT QUESTIONS


Detailed Table of Contents

[NEET PG 2024 AND INI-CET MAY 2024]

Sl. no. Subjects Covered Total Qs

1. ANATOMY 31

2. PHARMACOLOGY 41

3. PATHOLOGY 55

4. PREVENTIVE AND SOCIAL MEDICINE (PSM) 52

5. OTOLARYNGOLOGY 19

6. OPHTHALMOLOGY 25
Most Recent Questions
[NEET PG 2024 and INI-CET MAY 2024]

ANATOMY
a. A – Apocrine sweat gland, B – Arrector pilorum, C – Eccrine
NEET PG 2024 sweat gland, D – Sebaceous gland
b. A – Arrector pilorum, B – Apocrine sweat gland, C – Eccrine
1. Fracture at which site affects the longitudinal growth of a bone: sweat gland, D – Sebaceous gland
a. Epiphyseal plate b. Diaphysis c. A – Sebaceous gland, B – Eccrine sweat gland, C – Arrector
c. Epiphysis d. Metaphysis pilorum, D – Apocrine sweat gland
 [Ref: Gray’s Anatomy, 42nd ed., p. 97] d. A – Eccrine sweat gland, B – Arrector pilorum, C – Sebaceous
gland, D – Apocrine sweat gland
2. Chronic tobacco consumer went to dental clinic with bleeding  [Ref: diFiore’s Atlas of Histology with Functional
lesions on tongue was diagnosed with tongue carcinoma. Which Correlation, 11th ed., p. 219, 223]
of the papillae does not have taste buds?
a. Circumvallate 5. What is the outer covering of abnormal defect shown in the image?
b. Filiform
c. Fungiform
d. Foliate
 [Ref: diFiore’s Atlas of Histology with Functional
Correlation, 11th ed., p. 235, 236]
3. Where will you find the epithelium shown in the image?
a. Ureter
b. Gallbladder
c. Duodenum
d. Trachea
a. Endoderm b. Ectoderm
[Ref: diFiore’s Atlas of Histology
c. Chorion d. Amnion
with Functional Correlation,
11th ed., p. 38]  [Ref: Larsen’s Human Embryology, 6th ed., p. 82]

Explanation: Explanation: The covering of an omphalocele is a thin membrane made


y This image is transitional epithelium, also known as urothelium. of:
y Transitional epithelium allows distension of the urinary organs y Peritoneum: Covers the inner surface of the membrane
(calyces, pelvis, ureters, bladder) during urine accumulation and y Amnion: Covers the outer surface of the membrane
contraction of these organs, while the emptying process without y Wharton’s jelly: Located between the peritoneum and amnion
breaking the cell contacts in the epithelium. 6. Post ovulation, the oocyte is:
4. Identify the markers in the given slide: a. Primary oocyte arrested in prophase - I
b. Primary oocyte arrested in prophase - II
c. Secondary oocyte arrested in prophase - II
d. Secondary oocyte arrested in metaphase - II
 [Ref: Larsen’s Human Embryology, 6th ed., p. 27]

Explanation: The secondary oocyte promptly begins the second meiotic


division but, about 3 hours before ovulation, is arrested at the second
meiotic metaphase.

ANSWER KEY
ANATOMY
1. a 2. b 3. a 4. d 5. d 6. d
A

Anatomy
natomy
— Dr Shrikant Verma

SYNOPSIS

GENERAL ANATOMY

TYPES OF BONE

Bone types Appearance Function Picture Example(s)


Long bones Longer than they are wide Mechanical strength • Femur
• Tibia
• Fibula
• Humerus
• Ulna
• Radius
Short bones Cube-shaped Multidirectional motion Carpal bones (of the hands/
wrists) and the tarsal bones (of
the feet/ankles).

Flat bones Thin and flat bones have Mechanical protection to soft • Cranial bones
large surfaces for muscle tissues beneath • Sternum
attachments • Ribs
• Scapulae

Irregular bones Complicated shapes that Provide major mechanical • Vertebrae


cannot be classified as “long”, support for the body • Hyoid bone
“short” or “flat”. Vertebra protects the spinal • Sphenoid bone
cord • Facial bones

Sesamoid Most sesamoid bones are Protect from additional Only one type of sesamoid
bones un-named. friction and use - can form in bone is present in all normal
palms and soles human skeletons so it has a
name; the patella.
TEN into TEN 3

ANATOMY
Anatomy
Dr Shrikant Verma

GENERAL ANATOMY
[Total Questions 71]

1. Which of the following type of joint is present between the bones Explanation: Watershed areas
shown in the photograph? (INI-CET NOV 2023) y Regions of the brain lying at the extreme edges of the major cerebral
arterial territories are called watershed areas and are the first to be
deprived of sufficient blood flow in the event of cerebral hypoperfusion.
Ischemic infarcts of the cortex and adjacent subcortical white matter
in the border zones between these territories are known as watershed,
boundary-zone or border-zone infarcts
y The left colic flexure marks the junction between the transverse and
descending colons and lies in the left hypochondriac region, anterior
to the tail of the pancreas and the left kidney.

4. Coracoid process of scapula is:


a. Traction epiphysis b. Pressure epiphysis
c. Aberrant epiphysis d. Atavistic epiphysis
a. Gliding b. Pivot  [Ref: BD Chaurasia’s General Anatomy, 6th ed., p. 65;
c. Saddle d. Ball and socket Human Anatomy, 6th ed., vol. 1, p. 9]
 [Ref: Gray’s Anatomy, 42nd ed., International Edition, Explanation:
p. 748]
y Atavistic epiphysis is phylogenetically an independent bone which
Explanation: fused to another bone.
y Indicated joint is incudomalleolar joint which is saddle synovial joint y For example, coracoid process of scapula and os trigonum or lateral
while incudostapedial joint is ball and socket variety. tubercle of posterior process of talus.
y Mnemonic “SBI” 5. Example of traction epiphysis is:
S: Saddle joint a. Trochanters of long bone b. Carpals
B: Ball and socket joint c. Coracoid process d. Os trigonum
I: In front and behind the incus respectively
 [Ref: BD Chaurasia’s Handbook, 6th ed., p. 65]
2. For side-to-side movement (right-left movement) at the neck,
Explanation: Examples of traction epiphysis are trochanters of femur
which of the following joints is involved? (NEET PG 2019)
and tubercles of humerus.
a. Atlanto-axial joint
b. Atlanto-occipital 6. Which of the following is aberrant epiphysis?
c. Occipito-axial joint a. Greater tubercle of humerus
d. C6–C7 articulation b. Coracoid process
 [Ref: Gray’s Anatomy, 42nd ed., p. 839–841] c. Base of 1st metacarpal
d. Base of 2nd metacarpal
Explanation: Atlanto-axial joint (C1–C2 Joint) is classical example of  [Ref: BD Chaurasia’s General Anatomy, 6th ed.,
pivot joint which helps in rotatory movement of neck which results in p. 34, 65]
side-to-side movement/right-left movement/“No” movement

3. Structure not forming watershed area is:


a. Brain
ANSWER KEY
b. Splenic flexure
1. c 2. a 3. c 4. d 5. a 6. d
c. Duodenum
d. None of the above
 [Ref: Gray’s Anatomy, 42nd ed., p. 421, 1193]
52 MCQs

Explanation: Examples of Aberrant epiphysis are—epiphysis at the head 11. Largest carpal bone is:
of the 1st metacarpal and at the bases of other metacarpal bones. a. Capitate b. Hamate
c. Scaphoid d. Pisiform
7. Pisiform is which type of bone?  [Ref: Gray’s Anatomy, 42nd ed., p. 961,
a. Pneumatic bone BD Chaurasia’s Human Anatomy, 9th ed., vol. 1, p. 26;
b. Sesamoid bone 7th ed., vol. 1, p. 24 & 6th ed., p. 26]
c. Long bone
d. Accessory epiphysis Explanation: The capitate is the central and largest carpal bone.
 [Ref: Gray’s Anatomy, 42nd ed., p. 961; BD Chaurasia’s 12. Thinnest bony part is found in which of the following bone:
General Anatomy, 7th ed., vol. 1, p. 32 & 6th ed., p. 30, 55] a. Frontal b. Ethmoid
Explanation: The pisiform is a sesamoid bone within the tendon of c. Temporal d. Sphenoid
flexor carpi ulnaris that increases the flexion torque applied by the muscle.  [Ref: Gray’s Anatomy, 42nd ed., p. 699]

8. Carpometacarpal joint of thumb is: Explanation:


a. Saddle b. Hinge y The ethmoidal sinuses differ from the other paranasal sinuses in that
c. Pivot d. Ball and socket they are formed of multiple thin-walled cavities in the ethmoidal
 [Ref: Gray’s Anatomy, 42nd ed., p. 969, BD Chaurasia’s labyrinth.
General Anatomy, 6th ed., p. 103 & 6th ed., vol. 1, p. 157] y The number and size of the cavities vary, from 3 large to 18 small
sinuses on each side.
Explanation: They lie between the upper part of the nasal cavity and the orbit, and are
y The carpometacarpal joint of the thumb is a sellar joint between the separated from the latter by the paper-thin lamina papyracea or orbital
first metacarpal base and trapezium. plate of the ethmoid (this presents a poor barrier to infection, which may
y It is curved saddle shape, as if designed for a ‘scoliotic horse’ therefore spread into the orbit).

9. Median atlantoaxial joint is: 13. Which of the following is an atavistic epiphysis?
a. Cartilaginous a. Lower end of radius b. Condyles of femur
b. Condylar c. Coracoid process d. Tubercle of humerus
c. Fibrous  [Ref: BD Chaurasia’s Handbook 6th ed., p. 42;
d. Synovial joint BD Chaurasia’s Human Anatomy, 9th ed., vol. 1, p. 9]
 [Ref: Gray’s Anatomy, 42nd ed., p. 840; BD Chaurasia’s Explanation: The coracoid process of scapula is an atavistic type of
General Anatomy, 6th ed., p. 100 & Textbook of General Anatomy, p. 47]
epiphysis.
Explanation: 14. Which is not a type of epiphysis?
y Pivot (Trochoid) Joints—articular surfaces comprise a central bony a. Traction b. Atavistic
pivot (Peg) surrounded by an osteoligamentous ring. c. Pressure d. Friction
y Movements are permitted in one plane around a vertical axis.
 [Ref: BD Chaurasia’s Handbook of General Anatomy,
y For example, Superior and inferior radioulnar joints, median atlanto­
6th ed., p. 65]
occipital joints.
Explanation: Types of epiphyses:
10. The metopic suture:
According to number of epiphysis : Simple, compound
a. Separates frontal and parietal bones
According to the function: Pressure, traction, atavistic, aberrant, compound.
b. Separates occipital and parietal
c. Separates two halves of frontal bone 15. Epiphysio-diaphyseal joint is:
d. Separates two halves of the parietal bone a. Synostosis b. Syndesmosis
 [Ref: Gray’s Anatomy, 42nd ed., p. 558; BD Chaurasia’s c. Primarily cartilaginous d. Schindylesis
Human Anatomy, 7th ed., vol. 3, p. 5 & 6th ed., p. 5]  [Ref: BD Chaurasia’s Handbook, 6th ed., p. 64;
Handbook of General Anatomy, 6th ed., p. 95]
Explanation:
y Superomedial to each orbit is a rounded superciliary arch (more Explanation: Examples of primary cartilaginous joints: Joint between
pronounced in males), between which there may be a median epiphysis and diaphysis of a growing long bone, spheno-occipital joint,
elevation, the glabella. first chondrosternal joint, costochondral joints, xiphisternal joint.
y The glabella may show the remains of the interfrontal (metopic) suture,
which usually closes in the first postnatal year (Weinzweig et al. 2003) 16. Costochondral joint is example of:
but persists in a small percentage of adult skulls in various ethnic groups. a. Synovial joint
y A retained interfrontal suture is usually present in the inferior portion b. Primary cartilaginous joint
of the suture, a feature known as metopism. c. Secondary cartilaginous joint
d. Fibrous joint
ANATOMY

 [Ref: BD Chaurasia’s Human Anatomy, 7th ed., vol. 1,


ANSWER KEY
p. 217; 6th ed., p. 209 & Handbook of General Anatomy,
7. b 8. a 9. d 10. c 11. a 12. b
6th ed., p. 95]
13. c 14. d 15. c 16. b
Explanation: Refer explanation of Q. 15
TEN into TEN 57

60. Which of the following bones comprises seven in numbers? New Qs

a. Cervical vertebrae b. Carpals


c. Cranial bones d. Lumbar vertebrae
 [Ref: BD Chaurasia’s Human Anatomy, 9th ed., vol. 4, p. 34]

Explanation:
y Cervical vertebra are C1–C7.
y There are 8 carpals in each wrist.
y There are 8 cranial bones.
y There are 5 lumbar vertebrae.
y Different bones and their numbers shown in image:

ANATOMY

ANSWER KEY
60. a
Create a Study Schedule: Allocate specific times for anatomy review to
ensure consistent study habits and prevent cramming.
Pharmacology
P harmacology
— Dr Ranjan Kumar Patel

SYNOPSIS

GENERAL PHARMACOLOGY y Potency is a measure of drug dose, whereas efficacy is a measure of


maximum clinical effect produced by the drug.
y 100% bioavailability is achieved by intravenous route. y Dissociation constant or KD is the plasma concentration of drug at
y Most common mode of drug absorption is by passive diffusion. which 50% of the drug is bound to target.
Drugs ending with tide/ase/mab are proteins, have large size and y A graded DRC is drawn in an individual, whereas a quantal DRC is
cannot be absorbed by oral route. drawn in population.
y Unionization (lipid solubility) facilitates absorption whereas y In a graded DRC, height of the DRC is a measure of drug efficacy,
ionization (water solubility) facilitates excretion of drug. whereas the position of DRC on log dose axis indicates potency.
y pKa is the pH at which the drug is 50% ionized and 50% unionized. y In a quantal DRC, ED50 and TD50 can be calculated in humans and
y Bioavailability of a drug is calculated by formula AUCoral/AUCiv. animals, whereas LD50 can be calculated only in animals. ED50 is
It depends on absorption and first-pass metabolism. a measure of drug potency, whereas TD50 and LD50 are measure of
y Bioavailability or AUC determines extent of drug absorption, drug toxicity.
whereas Tmax determines rate of drug absorption. y In humans and animals, TD50/ED5 and LD50/ED50 are respectively
y Drugs with high volume of distribution are located in extravascular used to calculate therapeutic index. Therapeutic index is a measure
compartment, whereas drugs with low volume of distribution are of drug safety.
located in intravascular compartment. y A partial agonist behaves as an antagonist in presence of an
y Loading dose depends on aVd, whereas maintenance dose agonist. An inverse agonist is also an antagonist.
depends on clearance. y Most common antagonism encountered is competitive reversible
y Acidic drugs are bound to albumin, whereas basic drugs are bound antagonism. In this antagonism, DRC makes a right shift; efficacy
to alpha-1-acid glycoprotein. and Vmax are same; potency decreases and Km increases.
y The most common reaction of drug metabolism in phase I is y In noncompetitive antagonism, height of DRC decreases; efficacy
oxidation and phase II is glucuronidation. and Vmax decreases; potency and Km remains same.
y Most common CYP450 enzyme for drug metabolism is CYP3A4. y GPCRs are the most common target for drugs. GPCRs are also known
y All phase I reactions and only glucuronidation in phase II are as heptahelical, 7 transmembrane spanning and metabotropic
reactions by microsomal enzymes, i.e., in the sarcoplasmic reticulum. receptors.
y Enzyme inducers like rifampicin can cause OCP failure. Enzyme and y b receptors are Gs subtype, which act by increasing activity of
p-glycoprotein inhibitors like erythromycin/clarithromycin can adenylate cyclase and increasing cyclic AMP.
cause toxicity of drugs like digoxin, theophylline and statins. y Alpha receptors are Gq subtype, which act by increasing activity of
y In zero order, a constant amount is eliminated, whereas in first phospholipase-c and increasing IP-3.
order, a constant proportion is eliminated per unit time. y Good Clinical Practice (GCP) guidelines are for clinical trials
y In zero order, as dose increases T1/2 increases but clearance decreases; whereas Committee for the Purpose of Control and Supervision of
in first order, both T1/2 and clearance are constant. Experiments on Animals (CPCSEA) guidelines are for preclinical
y After 5 half-lives, a drug achieves steady state concentration. trials.
y Ligand-gated ion channels are fastest acting whereas nuclear y Pharmacokinetics and pharmacodynamics of a drug can be
receptors are the slowest acting receptors. determined in phase 0 and phase I clinical trial. Normal healthy
224 SYNOPSIS

Carcinoid tumors Octreotide Colorectal Ca • Drug of choice: 5-FU


• Regimen of choice:
Carcinomatous meningitis Methotrexate (Intrathecal)  FOLFOX – Folinic acid +
5-FU + Oxaliplatin
Cervical cancer Cisplatin  FOLFIRI – Folinic acid +
5-FU + Irinotecan
Choriocarcinoma Methotrexate
• Esophageal Ca
CLL • Regimen of choice: FCR
• Gastric Ca Cisplatin + 5-FU
• F: Fludarabine
• C: Cyclophosphamide
• R: Rituximab Hairy cell leukemia Cladribine

• CML Imatinib Hepatocellular carcinoma Sorafenib


• GIST
• Hypereosinophilic syndrome Hodgkin’s disease • Regimen of choice: ABVD
• Dermatofibrosarcoma • A: Adriamycin (Doxorubicin)
protuberans • B: Bleomycin
CML resistant to Imatinib • Ponatinib • V: Vincristine
• Nilotinib In case of relapse add – Nivolumab • D: Dacarbazine
• Bosutinib
• Dasatinib Kaposi sarcoma • Doxorubicin
Multi TK resistant (≥2) CML • Omacetaxine Or
• Asciminib • Daunorubicin
Contd...

Lung Cancer
y Small cell lung cancer
Cisplatin + Etoposide + Immunotherapy (Atezolizumab or Durvalumab)
y Non-small cell lung cancer
Refer to following flow chart to understand non-small cell lung cancer in detail.
PHARMACOLOGY

Named Trials in NSCLC


y Keynote 189 trial – Chemotherapy + Pembrolizumab
y Checkmate 227 trial – Ipilimumab + Nivolumab
Pharmacology
Dr Ranjan Kumar Patel

GENERAL PHARMACOLOGY
[Total Questions 79]

1. Which of the following drugs acts via the ATP-binding cassette Explanation: Lesser amount of drug present than expected in a tablet
transporter?  (INI-CET NOV 2023) makes it a spurious drug.
1. Verapamil 2. Diltiazem
3. Nifedipine 4. Tacrolimus 4. Which of the following acts by increasing phospholipase C?
a. 1 and 2 b. 1 and 3  (INI-CET MAY 2022)
c. 1, 2 and 4 d. 1, 3 and 4 a. Gs b. Gq
c. Gi d. Go
 [Ref: Internet] https://www.ncbi.nlm.nih.gov/.]
 [Ref: KD Tripathi, Essential of Medical Pharmacology,
Explanation: Non-DHPs are substrate for ABC Pumps (ATP Binding p. 55-57]
Cassette) or MDR-1/P-glycoprotein pump, but not DHPs.
Explanation: Gs acts via adenylate cyclase, whereas Gq acts via
2. Which of the following options is correct regarding drug receptor phospholipase C.
interaction given in the picture?  (INI-CET MAY 2022)
5. The graph given in the picture is an example of:
 (INI-CET MAY 2022)

a. A—Full agonist, B—Partial agonist, C—Antagonist,


D—Antagonist
b. A—Full agonist, B—Partial agonist, C—Inverse agonist,
D—Antagonist
c. A—Partial agonist, B—Full agonist, C—Inverse agonist,
D—Antagonist
d. A—Partial agonist, B—Full agonist, C—Antagonist, a. Competitive inhibition
D—Antagonist b. Noncompetitive inhibition
 [Ref: Goodman and Gilman’s The Pharmacological Basis c. Uncompetitive inhibition
of Therapeutics, 13th ed., p. 54-70] d. None of the above
 [Ref: Goodman and Gilman’s The Pharmacological Basis
Explanation: An inverse agonist is also an antagonist. of Therapeutics, 13th ed., p. 47]
3. A brand markets Paracetamol as 400 mg but it only has 200 mg.
The drug will be called a: (INI-CET MAY 2022) ANSWER KEY
a. Spurious drug b. Adulterated drug 1. c 2. a 3. a 4. b 5. a
c. Unethical d. Misbranded
 [Ref: KD Tripathi. Essentials of Medical Pharmacology,
8th ed., p. 223-24]
234 MCQs

28. True about pKa is: Explanation: Reactions of Phase I and II


a. pH at which ionized fraction of drug equals to unionized fraction
b. pH at which ionized fraction of drug is more than unionized Mnemonics
fraction Phase I: ORCHAD Phase II: GAMS
c. pH at which ionized fraction of drug is less than unionized O : Oxidation G : Glucuronidation,
fraction R : Reduction Glutathionylation, Glycination
d. pH at which ionized fraction of drug is twice unionized fraction C : Cyclization A : Acetylation
 [Ref: Goodman and Gilman’s The Pharmacological Basis H : Hydrolysis M : Methylation
of Therapeutics, 12th ed., p. 18] A:A  liphatic and aromatic S : Sulfation
hydroxylation
Explanation: pKa is the pH at which a drug is 50% ionized and 50% D : Deamination
unionized, i.e., the fraction of ionized drug equals to the fraction of
unionized drug. In phase I grow fruits in an ORCHAD and then in phase II make fruit
GAMS.
29. Digoxin has a half-life of 40 hours, which helps in prescribing to
determine: 32. Which of the following is true regarding a drug with high plasma
a. Regimen for smooth discontinuation protein binding?
b. Need for loading dose in order to give immediate effect a. Decreased glomerular filtration
c. Regimen for maintenance dose b. Decreased tubular secretion
c. Increased volume of distribution
d. Can be given once in 2 days
d. Less drug interaction
 [Ref: Goodman and Gilman’s The Pharmacological Basis
 [Ref: Goodman and Gilman’s The Pharmacological Basis
of Therapeutics, 12th ed., p. 37] of Therapeutics, 13th ed., p. 18]
Explanation: Half-life tells us about the time we need to achieve steady Explanation: It is a basic concept in physiology that proteins can never
state, i.e., 4–5 half lives. get filtered out from a normal kidney as the glomerular bed is charged
Thus for digoxin, it will require 200 hours to achieve steady state. and proteins are also charged particles.
Hence, to achieve steady state faster loading dose is given. Hence, plasma protein bound drugs cannot undergo glomerular
30. Loading dose of a drug primarily depends on: filtration.
a. Volume of distribution Though plasma protein bound drugs can undergo tubular secretion.
b. Clearance 33. Drug transport across the cell membrane is mainly by:
c. Rate of administration a. Passive transport b. Active
d. Half-life c. Facilitated d. Pinocytosis
 [Ref: Goodman and Gilman’s The Pharmacological Basis  [Ref: Goodman and Gilman’s The Pharmacological Basis
of Therapeutics, 12th ed., p. 37] of Therapeutics, 12th ed., p. 20]

Explanation: Loading dose Explanation: Most common process of drug absorption is passive
diffusion through lipid barrier and hence, it is generalized that a drug is
aVd = D/C
absorbed when it is in lipid soluble form.
or D = aVd × C
34. Ciprofloxacin should not be given to an asthmatic using
The plasma concentration must be specific for a particular clinical effect. theophylline because:
If drug has a high volume of distribution, then to maintain a specific a. Ciprofloxacin inhibits theophylline metabolism
plasma concentration, in the equation above we must increase the dose b. Theophylline inhibits ciprofloxacin metabolism
“D” of the drug. This increased dose of drug for drugs with high aVd to c. Ciprofloxacin decreases effect of theophylline
maintain a specific plasma concentration is known as loading dose. Thus d. Theophylline induces metabolism of ciprofloxacin
loading dose depends on aVd and the formula for calculation is,
 [Ref: Goodman and Gilman’s The Pharmacological Basis
Loading dose (LD) = aVd × C
of Therapeutics, 19th ed., p. 130]
31. In metabolism of xenobiotics, all of the following reactions occur
35. False regarding Cytochrome P-450 is:
in phase one; except:
a. They are essential for the production of cholesterols, steroids,
a. Oxidation prostacyclins and thromboxane A2
b. Reduction b. They absorb light with 450 nm wavelength
c. Conjugation c. They occur predominantly in liver
PHARMACOLOGY

d. Hydrolysis d. They are non-heme proteins


 [Ref: Goodman and Gilman’s The Pharmacological Basis  [Ref: Basic and Clinical Pharmacology by
of Therapeutics, 12th ed., p. 138] Katzung, 12th ed., p. 55]

ANSWER KEY
28. a 29. b 30. a 31. c 32. a 33. a
34. a 35. d Generic and brand names of drugs are often tested.
324 MCQs

1005. Ciraparantag is a wide spectrum antidote against all of the following drugs; except: New Qs

a. Heparin b. Fondaparinux
c. DOAC d. Warfarin
 [Ref: Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 13th ed., p. 720, 726]

Explanation:

1006. A patient was started on warfarin and developed the side- 1007. A patient on anticoagulation therapy developed the side-effect
effect given in the image. All of the following can be used in given in picture. Which of the following might be the reason for
management; except: New Qs the same? New Qs

a. Protein C concentrate b. FFP


c. Vitamin K d. 4 factor PTC
 [Ref: Goodman and Gilman’s The Pharmacological Basis
of Therapeutics, 13th ed., p. 717-718]
PHARMACOLOGY

Explanation: Warfarin-induced skin necrosis is due to rapid decline in


a. Paradoxical thrombosis
protein C. 4 factor prothrombin complex has factor II, VII, IX, X, but no b. Cholesterol embolization
protein C; hence, it cannot be used. c. Drug induced pigmentation
d. Vasoconstriction
 [Ref: Goodman and Gilman’s The Pharmacological Basis
ANSWER KEY of Therapeutics, 13th ed., p. 717-718]
1005. d 1006. d 1007. b
Explanation: Warfarin-induced purple toe is due to cholesterol
embolization.
P

Pathology
athology
— Dr Preeti Sharma

SYNOPSIS

TYPES OF NECROSIS

Necrosis Features Images Necrosis Features Images


Coagulative • Most common Caseous • Combination
necrosis necrosis necrosis of coagulative
• Seen in solid and liquefactive
organs necrosis
• Tissue architecture • Causes:
preserved  TB
• Microscopically  Histoplasmosis
ghost cells seen • Grossly cheesy
appearance noted
Fat necrosis • Seen in breast and
omentum.
• Characterized
by deposition
of chalky white
calcium
Liquefactive Seen in brain and
necrosis/ pancreas
Fibrinoid • Seen in
colliquative
necrosis  PAN
necrosis
 SLE
 RHD
 Malignant HTN

CASPASES AND MARKERS

Apoptosis initiation Caspase 8, 9, 10


Apoptosis execution Caspase 3, 6, 7
Apoptosis marker Annexin V
Apoptosis molecular marker CD 95/Fas
Pyroptosis Caspase 1, 4, 5, 11
Pathology
Dr Preeti Sharma

GENERAL PATHOLOGY
[Total Questions 293]

CELL INJURY a. 1-D, 2-C, 3-B, 4-A b. 1-C, 2-A, 3-D, 4-B
c. 1-A, 2-B, 3-D, 4-C d. 1-B, 2-A, 3-C, 4-D
1. Which of the following are the features of necrosis?  [Ref: Internet]
(INI-CET MAY 2023) 6. Which of the following are true regarding sirtuins? 
a. Disrupted cell membrane b. Induces inflammation 1. Increases insulin sensitivity  (INI-CET NOV 2022)
c. Cell swelling d. Physiological 2. Promotes genes which increase longevity
a. a and b b. a, b and d 3. They are 7 types
c. a, b and c d. a and c 4. Is a type of histone deacetylase
 [Ref: Robbins and Cotran, 10th ed., p. 39] a. 1, 2, 3 b. 1, 2, 3, 4
c. 2, 3 d. 2, 4
Explanation: Necrosis is always pathological. Apoptosis can be both  [Ref: Robbins and Cotran, 10th ed., p. 68]
physiological as well as pathological.
7. Cell in cell appearance is seen in: (INI-CET MAY 2022)
2. Which of the following is an antiapoptotic gene? a. Necrosis b. Apoptosis
 (INI-CET MAY 2023) c. Necroptosis d. Emperipolesis
a. BAK b. BAX  [Ref: Internet]
c. Mcl-1 d. PUMA
 [Ref: Internet] Explanation: Emperipolesis is defined as cell in cell appearance without
killing. It is seen in
Explanation: Bcl-2, Mcl-1, Bcl-XL are antiapoptotic. P53, BAK, BAX, y MDS/MPN y Rosai-Dorfman Disease
Bcl-XS are proapoptitic. y Autoimmune hepatitis y CLL
3. Abnormal folding of proteins causes which of the following 8. True statement of telomerase theory of aging is: (NEET PG 2022)
disease? (INI-CET MAY 2023) a. Increasing telomere length is proportional to aging
a. Creutzfelt-Jakob disease b. Cirrhosis b. Telomere mutation is associated with increased aging
c. Nephritic syndrome d. Sickle cell anemia c. Decreased telomere length is associated with aging
 [Ref: Harsh Mohan, Textbook of Pathology, d. Increased telomerase activity is associated with aging
8th ed., p. 925]  [Ref: Robbins and Cotran, 10th ed., p. 66–69]

Explanation: Abnormal folding of proteins is seen in prion diseases Explanation: Cellular aging is due to telomere shortening. One telomere
(e.g., CJ disease). This causes spongiform changes/vacuolations in CNS, sequence is TTAGGG.
thereby also known as transmissible spongiform encephalopathy (TSE).
9. Which of the following will increase life span/delay the aging
4. Senile atrophy is seen in: (INI-CET NOV 2022) process? (NEET PG 2022)
a. Denervation b. Decreased nutrition a. Regular exercise
c. Decreased workload d. Reduced blood supply b. Decrease stress
 [Ref: Robbins and Cotran, 10th ed., p. 60] c. Decrease calorie by 30%
d. Pharmacological intervention by taking PPIs
5. Match the following stains and the tissue. (INI-CET NOV 2022)  [Ref: Robbins and Cotran, 10th ed., p. 68]
Column A Column B
1. Prussian blue stain A. Iron ANSWER KEY
2. PAS stain B. Glycogen 1. c. 2. c. 3. a. 4. d. 5. c. 6. b.
3. Congo red stain C. Leprosy 7. d. 8. c. 9. c.
4. Fite–Faraco stain D. Amyloid
TEN into TEN 395

338. An adult male patient presented with shortness of breath, 342. A middle aged immunocompromised man came with fever
hemoptysis and weight loss. On examination, hilar mass and breathlessness. HRCT showed a middle lobe lesion with
was present. Histopathological image is shown as follows. infiltration. Lung biopsy from the lesion is shown as follows.
Immunohistochemistry revealed that the cells were positive for Diagnosis is:
p40. What is the diagnosis? (INI-CET NOV 2022)

a. CMV organizing pneumonia


b. Cryptogenic organizing pneumonia
c. Small cell carcinoma lung
a. Squamous cell carcinoma b. Adenocarcinoma lung d. Organized Pneumonia with tuberculosis
c. Small cell cancer lung d. Large cell carcinoma  [Ref: Robbins and Cotran, 10th ed., p. 356–357]
 [Ref: Internet] Explanation: Cytomegalovirus (CMV) infection shows intranuclear
and intracytoplasmic inclusions. Appearance of intranuclear inclusions is
Explanation: Squamous cell carcinoma lung shows keratin pearls
known as owl eye appearance.
histologically. Immunohistochemistry shows positivity for p63 and p40
(best marker). 343. Gross specimen of lung from a patient is shown in the following
figure. What is the most probable diagnosis?
339. A chronic smoker presents with shortness of breath. A mass is
noted at the lower lobe periphery of the lung. Biopsy is performed
and histopathological examination reveals lung adenocarcinoma.
The biopsy will be positive for: (INI-CET NOV 2022)
1. TTF-1 2. P40
3. Napsin A 4. Chromogranin
a. 1, 2 b. 1, 3
c. 1, 4 d. 2, 4
 [Ref: Internet]

Explanation: Lung adenocarcinoma is positive for TTF1, NAPSIN A


and Muc 1.
340. A 70-year-old patient presented with cough, fatigability and a. Pneumoconiosis b. Miliary tuberculosis
weight loss. He was diagnosed with squamous cell carcinoma on c. Bronchiectasis d. Pneumonia
bronchoscopy. Resected specimen also had hilar lymph node 1 cm  [Ref: Internet]
in size and it showed black pigment. What is the black pigment
likely to be? (INI-CET JULY 2021) 344. Whole blood is used in diagnosis of TB in:
a. Anthracotic pigment b. Melanin a. Gamma interferon assay b. Gene Xpert
c. Lipochrome d. Hemosiderin c. Bactec test d. Blood culture
 [Ref: Internet]  [Ref: Internet]

Explanation: Whole blood is used in diagnosis of latent Tb using Quan-


Explanation: Anthracotic pigment (carbon) gives a black color to lung.
tiferon GOLD/ Interferon gamma release assay (IGRA).
This is commonly seen in smokers and persons working in the coal
This tests measures T-cell release of IFN-γ following stimulation by
industry.
antigens specific to the M. tuberculosis complex, i.e., ESAT-6 and CFP-10.
341. Alpha-1 antitrypsin acts to prevent lung tissue destruction by:
(NEET PG 2019)
a. Inhibiting the release of trypsin
PATHOLOGY

b. Inhibiting the activation of trypsinogen


c. Inhibiting the release of chymotrypsin
ANSWER KEY
d. Inhibiting the elastase in lung
338. a. 339. b. 340. a. 341. d. 342. a. 343. b.
 [Ref: Internet]
344. a.
Explanation: Alpha-1 antitrypsin is an anti-elastase or anti-protease.
396 MCQs

345. A middle aged man comes with breathing difficulty. He gives 346. A patient presented with 4-month history of cough with diarrheal
history of working in a factory. Lung fibrosis and pleural thickening episode. Bronchoscopy revealed an intrabronchial polyp. Biopsy
where observed and biopsy was taken. On histopathological from the polyp showed atypical cells with microscopic necrosis
examination, the following picture of lung parenchyma was seen. and 5 mitotic figures per 10 high-power fields shown as follows.
Most likely diagnosis is? Chromogranin staining was positive. What is the diagnosis and
grade of the lesion?

a. Silicosis a. Typical carcinoid


b. Coal workers’ pneumoconiosis b. Atypical carcinoid
c. Asbestosis c. Small cell carcinoma
d. Byssinosis d. Large cell neuroendocrine carcinoma
 [Ref: Robbins and Cotran, 10th ed., p. 280t, 694, 695t]  [Ref: Internet]

Explanation: Histopathological image shows dumbbell shaped Asbestos Explanation: Typical carcinoids have a mitotic rate of 2 mitoses/2
Bodies/ Ferruginous bodies. These show deposition of iron around the mm2 and no necrosis, while atypical carcinoids have a mitotic rate of
asbestos fibres and stain positive for Perl’s or Prussian blue. 2–10 mitoses/2 mm2 or necrosis.

347. Which type of paraneoplastic syndrome is most commonly associated with small cell lung carcinoma?
a. SIADH b. Gynecomastia
c. Acanthosis nigricans d. Hypocalcemia
 [Ref: Robbins and Cotran, 10th ed., p. 1074]

Explanation: SIADH is most commonly associated with small cell lung carcinoma/ oat cell cancer.
Paraneoplastic syndromes associated with lung carcinoma
Features Squamous cell carcinoma Adenocarcinoma Small cell carcinoma Large cell cancer
Paraneoplastic Hypercalcemia Migratory thrombophlebitis SIADH, Lambert-Eaton syn- Gynecomastia
syndrome drome, Cushing’s disease

348. Malignancy associated hypercalcemia is due to:


Explanation:
a. Tumor lysis syndrome
b. Parathyroid related peptide Thickness of submucosal gland
Reid index =
c. IL-7 Overall thickness of wall
d. Hypocalcemia
 [Ref: Internet] Normal RI = 0.4
RI is increased in chronic bronchitis
349. Reid’s index is? New Qs

a. Increased in chronic bronchitis 350. Most common cause of atypical pneumonia is: New Qs

b. Decreased in chronic bronchitis a. Mycoplasma pneumoniae


c. Increased in bronchial asthma b. Streptococcus pneumoniae
d. Decreased in bronchial asthma c. Measles
 [Ref: Internet] d. Haemophilus influenzae
 [Ref: Internet]
PATHOLOGY

Explanation:
ANSWER KEY Most common cause of atypical pneumonia or walking pneumonia is My-
coplasma pneumoniae.
345. c. 346. b. 347. a. 348. b. 349. a. 350. a.
Mycoplasma is the smallest bacterium and does not have a cell wall.
It shows fried egg colonies on PPLO agar which are visualized by
staining with Diene’s stain.
P

PSM
reventive and Social Medicine (PSM)
— Dr Mukhmohit Singh

SYNOPSIS

PRINCIPLES OF EPIDEMIOLOGY

Cross-sectional Ecological Case control Cohort


Also known as Snapshot of population Correlational study Retrospective study Prospective study
Unit Individual Population Individual Individual
Start with Total population Data sources for population Disease and non-disease Risk factor exposed and nonexposed
Use Prevalence Correlation of variables Odds ratio Risk ratio, attributable risk
Bias Selection bias Ecological fallacy Recall bias Hawthorne effect, attrition bias
Multiple risk factors can be Multiple outcomes can be assessed
assessed
Rare disease Rare risk factors
Effect to cause Cause to effect
Less expensive, less time More expensive, more time

Formula y Indirect standardization: If the age specific death rates of population


is NOT available, we can calculate the standardized mortality ratio
y Odds ratio: Cross product ratio (SMR) by comparing with the total deaths with reference population
y Relative risk: Incidence exposed/Incidence nonexposed as follows: Observed deaths
y Attributable risk: Incidence exposed—Incidence nonexposed)/ SMR = × 100
Expected deaths
incidence exposed

Treatment PRINCIPLES OF SCREENING FOR DISEASE


Bias: Blinding (triple blind is best type of blinding) y Sensitivity: Probability of having test positive out of total diseased.
y Specificity: Probability of having test negative out of total healthy.
Confounder y Positive predictive value: Probability of having disease out of total
tested positive.
Known confounder: Matching
y Negative predictive value: Probability of having disease out of
Unknown confounder: Randomization, regression, stratification, total tested negative.
standardization y Likelihood ratio:
sensitivity
Standardization  For positive test =
1 – specificity
y Direct standardization: If the age specific death rates of population is 1 – sensitivity
 For negative test =
available, we can directly compare with reference population. specificity
TEN into TEN 487

y JE vaccine—till 15 years Heat sensitive vaccine: OPV > Measles or MR > BCG
y Hep B (birth dose)—till 24 hours of birth Freeze sensitive vaccine: Hep B > Pentavalent > DPT
y OPV (zero dose)—till 15 days of life
Cold chain temperature— +2° to +8°C Cold Chain Equipment
y Vaccine carrier: 16–20 vials, 4 ice packs
Vaccine Vial Monitor
y Cold boxes: 75–300 vials (depending on size—5 liters or 20 liters)
y Qualitative check for effectivity of heat sensitive vaccines with ice packs.
y Discard point—square becomes same color (or darker) than the
outer circle Ice Lined Refrigerator
y Vaccine vials which have VVM on body follow open vial policy. y Needs at least 8-hour electricity in 24 hours to maintain temperature
y Storage:
 Diluents always kept in top shelf of ILR
 In upper shelves of ILR—Freeze sensitive vaccines
 In bottom shelves of ILR—heat sensitive vaccines
y Use dial thermometer for temperature recording (usually done twice
daily).
Discard point is – Image D

PREVENTIVE AND SOCIAL MEDICINE (PSM)


Ice lined refrigerator

Shake Test y Malaria: Mosquirix vaccine (RTS,S AS01 vaccine)


y Leprosy: Mycobacterium indicus pranii (MW vaccine—older name)
y For freeze sensitive vaccines (hepatitis B, DPT, TT, Td, Typhoid y Typhoid:
vaccines)  Oral typhi 21 a—live vaccine
y It is not to be performed for OPV, measles and BCG vaccines.  Vi polysaccharide vaccine—for age >2 years
Open Vial policy: All vaccines can be reused within 28 days of opening,  Typhoid conjugate vaccine—single dose for high risk susceptible
EXCEPT BCG and MR vaccine. y Meningococcal: A,C, W135, Y quadrivalent vaccine
y Pneumococcal: Pneumococcal conjugate vaccine, Pneumococcal
Strains of Vaccine polysaccharide vaccine.
y Yellow fever: 17 D, live vaccine, one dose given in lifetime y COVID Vaccines
y BCG: Danish 1331, live attenuated  Viral vector vaccines:
y OPV: SABIN strain ™ Covishield—using CHAD-OX1 strain, with chimpanzee
y IPV: SALK adenovirus
y Chicken pox: OKA vaccine, live vaccine ™ Sputnik—human adenovirus vaccine
y Measles: Edmonston zagreb ™ Janssen—viral vectored vaccine by Johnson and Johnson
y Mumps: Jeryll Lyn ™ INCOVACC (2022)—BBV154 nasal vaccine
y Rubella: RA 27/3 Winstar vaccine » Recombinant replication deficient adenovirus vectored
y Plague: Modified Sokhey vaccine vaccine with a prefusion stabilized spike protein
PSM
Dr Mukhmohit Singh

MEDICAL RESEARCH
[Total Questions 222]

PRINCIPLES OF EPIDEMIOLOGY 4. A study was conducted to find the association of aniline dye and
bladder cancer. Study was done by comparing two groups of people
1. What kind of study is longitudinal and analytical? working in aniline dye factory and those who are office workers
a. Ecological study [INI-CET NOV 2023] of same factory using records of employment for past 20 years to
b. Cross-sectional study assess the risk. What is the type of study? (NEET PG 2023)
c. Case control study a. Retrospective cohort b. Prospective cohort
d. Randomized clinical trials c. Case control d. Intervention and response
 [Ref: Park’s Textbook of Preventive and Social Medicine,
 [Ref: Park’s Textbook of Preventive and Social Medicine,
27th ed., p. 84]
27th ed., p. 78]
Explanation: In retrospective Cohort (or historical cohort) study,
Explanation: Case control and Cohort studies are longitudinal studies.
the researcher goes back in time to select people with risk factor using
y Case control is retrospective and Cohort study is prospective study previous employment or medical records.
design.
y Cross-sectional is transverse study. 5. A 10-year-old child in a school should be given which of the
y Ecological is correlational study. following vaccines? (NEET PG 2023)
a. Td vaccine b. Rota virus vaccine
2. About 30,000 women were followed-up for 10 years for c. Measles vaccine d. Hepatitis B vaccine
development of breast cancer. 1200 women developed cancer  [Ref: Park’s Textbook of Preventive and Social Medicine,
and were given questionnaire for assessing possible risk factors. 27th ed., p. 136]
Additionally, 2000 women from the same study were used as
control and they were also given questionnaire. What is this type Explanation: National immunization schedule for infants and children
of study called? (INI-CET MAY 2023) 2020 states TT/Td for 10 years and 16 years, dose of 0.5 mL intramuscular
a. Nested case control b. Case Cohort study in upper arm.
c. Retrospective cohort d. Cross control cohort 6. Which of the following options are correct? (INI-CET NOV 2022)
 [Ref: Conceptual Review of PSM, CBS Publishers, 1. VVM has a chemical indicator in the circle, which changes color
3rd ed., p. 4] 2. VVM gives an idea for number of days for expiry of vaccine
3. It is the only tool among all time temperature Indicators that is
Explanation: In this MCQ, there is a follow-up for 30,000 females for a available at any time in the process of distribution and at the time
period of 10 years and which makes this as a Cohort study, but also it is a vaccine is administered at health center
mentioned that 2000 females from the same study Cohort were used as 4. It indicates whether the vaccine has been exposed to a
controls to do the study and therefore, this study is a nesting of the case combination of excessive heat over time and whether it is likely
control study within the same Cohort which is technically called a nested to have been damaged
case control study. 5. VVM tells about the efficacy of the vaccine
6. The expiry date of the vaccine can be relaxed if the VVM is intact
3. Which of the following is not correctly matched? a. 1, 2, 4 correct b. 1, 3, 5 are correct
a. Systematic review—PRISMA (INI-CET MAY 2023) c. 3 and 4 are correct d. All are correct
b. Diagnostic studies—CONSORT  [Ref: Park’s Textbook of Preventive and Social Medicine,
c. Observational studies—MOOSE 27th ed., p. 122]
d. Case report—CARE
 [Ref: Conceptual review of PSM, CBS Publishers, ANSWER KEY
3rd ed., p. 187]
1. c 2. a 3. b 4. a 5. a 6. c
Explanation: CONSORT is done for Randomized control trials and not
for diagnostic studies.
TEN into TEN 505

32. When we are investigating the relationship between steroid 36. What is not true about cross-sectional study?
contraceptive and breast cancer, if the women taking these a. Estimate for prevalence of disease
contraceptives are younger than those in the comparison group, they b. Confirms the etiology of disease
would be at a lower risk of breast cancer since this disease becomes c. Evaluate the disease pattern in the community
common with increasing age. The age factor in this case is called: d. Evaluate the association of risk factors
a. Selection bias b. Berksonian bias  [Ref: Park’s Textbook of Preventive and Social Medicine,
c. Confounding factor d. Interviewer bias 27th ed., p. 77]
 [Ref: Park’s Textbook of Preventive and Social Medicine,
Explanation: The etiology of the disease cannot be estimated by a
27th ed., p. 80]
cross-sectional study.
Explanation: Confounding factor: The causation of disease (or etiology) may be best measured by
y Is present in both the groups to be assessed (but in unequal Cohort (follow-up) studies.
proportions). Cross-sectional study—salient features:
y It is associated with both disease and the risk factor. y Estimate for the prevalence of the disease
y Evaluation of the risk factors for the disease
33. Best way to avoid known confounders is: y Assess the epidemiological determinants as pattern of disease—host
a. Standardization b. Stratification factors, age groups and other related variables may be assessed.
c. Regression d. Matching
37. For calculation of incidence, denominator is taken as:
 [Ref: Internet]
a. Mid-year population b. Population at risk
Explanation: Treatment of known confounders c. Total number of cases d. Total number of deaths
� Matching � Randomization  [Ref: Park’s Textbook of Preventive and Social Medicine,
Treatment of unknown confounders 27th ed., p. 68]
� Regression � Randomization
Explanation: Incidence is “Number of new cases of a disease or new spells/
� Standardization � Stratification
episodes of sickness occurring in a defined population during a specified
34. Population at risk is used as denominator in calculation of: period of time”.
a. Mortality rate Number of new cases of
b. Incidence specific disease during a given time period
Incidence rate =
c. Prevalence Population at risk during that period
d. Relative risk
38. True regarding prevalence is:
 [Ref: Park’s Textbook of Preventive and Social Medicine, a. Cannot be used to determine the health needs of a community
27th ed., p. 68] b. Independent of incidence
c. Independent of duration
Explanation: Incidence is given by the formula:
d. Measures all cases
Number of new cases of  [Ref: Park’s Textbook of Preventive and Social Medicine,
specific disease during a given time period 27th ed., p. 69]
Incidence = × 1000
Population at-risk during that period
The point prevalence is given by the formula: Explanation: Prevalence measures all current cases (old and new) in a

PREVENTIVE AND SOCIAL MEDICINE (PSM)


given population.
Number of all current cases (old and new) of a
Uses of Prevalence
specified disease existing at a given point in time
= × 100 y Estimate magnitude of health/disease problem in the community and
Estimated population at the same point in time identify potential high-risk populations.
y Administrative and planning purposes, e.g., hospital beds, manpower
35. A village with 2000 population was surveyed for 1 year and
needs, rehabilitation facilities, etc.
10 were found to be diseased. Assuming that the disease lasts for
2 years, annual prevalence is: 39. Age adjusted death rate is calculated for all; except:
a. 10/4000 per 1000 population a. To allow communities with different age structures to be compared
b. 20/2000 per 1000 population b. To allow comparison of both sexes
c. 10% c. To allow comparison of different age in relation to injuries or
d. 0.5% accidents
 [Ref: Park’s Textbook of Preventive and Social Medicine, d. To allow comparison of cancer prevalence in different strata
27th ed., p. 69]  [Ref: Park’s Textbook of Preventive and Social Medicine,
27th ed., p. 65]
Explanation: Prevalence: It is the total number of cases present (both
Explanation: “Age adjusted death rate” removes confounding effect of
old and new) in an area in a population.
In the MCQ, the total cases found in the survey = 10 different age structures in population and helps compare mortality.
Population under survey = 2000: Adjustment can be made for age, sex, race, parity, etc.
So, the prevalence is calculated as
Prevalence = Total cases × 100 = 0.5% ANSWER KEY
Population under surgery 32. c 33. d 34. b 35. d 36. b 37. b
Usually, the prevalence is expressed as a percentage (proportion) and 38. d 39. b
incidence is expressed as rate per 1000 population per unit time.
Otolaryngology
O tolaryngology
— Dr Rajiv Dhawan

SYNOPSIS

OTOLOGY

INNER EAR (LABYRINTH) Benign Paroxysmal Positional Vertigo (BPPV)


y This disease is more common in females.
Basal turn of cochlea Senses high frequency sounds 8000 Hz y Etiology: Otoconia reaches the semicircular canal (Most common is
Apex turn (Helicotrema) Senses low frequency sounds 250 Hz posterior SCC).
y Chief complaint: Vertigo for few seconds on changing head
position. No hearing loss/tinnitus.
y Diagnostic test of BPPV: Dix Hallpike’s Maneuver.
y Treatment of BPPV: Epley maneuver (particle repositioning
maneuver).

Fitzgerald-Hallpike Bithermal Caloric Test


y This is a test for lateral SCC
 With cold water stimulation, eyes move toward the opposite
side.
 With warm water stimulation, eyes move toward the same side.
(COWS).

Auditory Pathway
Parts of inner ear Functions Sensory end organs Mnemonics
Cochlea Hearing Organ of corti y It mainly lies in the brainstem area.
Utricle and saccule Linear balance Macula  E—Eighth nerve (spiral ganglion of 8th nerve in modiolus of
Cochlea).
Semicircular canals Angular balance Crista
 C—Cochlear nucleus.
 O—Olivary complex (superior)—the site of cross over of
UTRICLE AND SACCULE (OTOLITHIC ORGANS) information and sound localization.
 L—Lateral lemniscus.
Utricle Horizontal linear balance.
 I—Inferior colliculus.
 M—Medial geniculate body.
Saccule Vertical linear balance.  A—Auditory cortex.
TEN into TEN 649

Two Special Audiograms y BERA has 7 waves. (I to VII)


y The most important wave of BERA is wave V, it is produced by lateral
lemniscus.

OTOACOUSTIC EMISSIONS (OAE)


y Emission means echoes.
Meniere’s Disease—Rising curve (Unilateral)
y Principle: We give sound to ear and then we record echoes from
outer hair cells of cochlea. These echoes are called Otoacoustic
emissions.
y If echoes are recorded it means cochlea is working normally.

IMPEDANCE AUDIOMETRY (TYMPANOMETRY)


Type A Normal
Presbyacusis—Sloping curve (Bilateral) Type B Flat curve seen in glue ear (or in perforated ear drum)
Type C Seen in ET dysfunction or retracted tympanic membrane.
BRAINSTEM EVOKED RESPONSE This curve only comes on the negative side.
AUDIOMETRY (BERA) Type As Seen in Otosclerosis. It is a low compliance curve.
y Principle: We stimulate the ear with sound and record electrical Type Ad Seen in ossicular dislocation. It is a high compliance curve
activity from the auditory pathway (it lies mainly in brainstem area). (open ended curve).
OTOLARYNGOLOGY
Otolaryngology
Dr Rajiv Dhawan

EAR
[Total Questions 337]

1. A 30-year-old female patient presents in the OPD with hearing loss 3. A patient presents to the OPD with the complaints of episodic
in both ears since last 1 year. Investigations confirm the diagnosis vertigo which is sudden onset, and right sided sensorineural
of otosclerosis with more hearing loss on right side. Patient was hearing loss (SNHL), and Tinnitus which lasts minutes to hours
advised to have Stapedotomy. Which of the following will be the with accompanied nausea, vomiting and vagal symptoms. What
tuning forks findings? (INI-CET NOV 2023) is the diagnosis of the patient in accordance with the given
a. Right Rinne’s positive and Weber lateralized to left ear audiogram? (INI-CET NOV 2023)
b. Right Rinne’s negative and Weber lateralized to right ear
c. Left Rinne’s positive and Weber lateralized to right ear
d. Left Rinne’s negative and Weber lateralized to left ear
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 25]

Explanation: It is a case of bilateral conductive hearing loss with right


being poor ear. In CHL, Rinne is negative and Weber is lateralized to
poor ear.
2. A patient presents to the OPD with the complaint of hearing loss
and can understand only shouted or amplified speech. What will
be the degree of impairment according to the WHO classification
of ability to understand speech? (INI-CET NOV 2023)
a. Mild hearing loss b. Severe hearing loss
c. Profound deafness d. Moderate hearing loss
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 44]
a. Meniere’s disease b. BPPV
Explanation:
c. Acoustic neuroma d. None
Grade of Corresponding Performance  [Ref: Diseases of Ear, Nose and Throat and
impairment audiometric ISO Neck Surgery by PL Dhingra, 8th ed., p. 119]
value (average of
500, 1000, 2000, Explanation: Meniere’s disease is the most likely possibility which is
4000 Hz) of the mostly unilateral with low frequency SNHL in early stages with rising
better ear audiogram.
No 25 dB or better No or very slight hearing problems
Able to hear whispers
Slight 26–40 dB Able to hear and repeat words
spoke in normal voice at 1 meter
Multiple quick revisions are better than single exhaustive revision.
Moderate 41–60 dB Able to hear and repeat words
using raised voice at 1 meter
Severe 61–80 dB Able to hear some words when
ANSWER KEY
shouted into better ear
1. b 2. b 3. a
Profound 81 dB or greater Unable to hear and understand
even shouted voice
TEN into TEN 669

11. A patient presents to ENT OPD with the chief complaint of Explanation: This child is suffering from adenoid hypertrophy with glue
hearing loss. The pure tone audiometry has been done and the ear as per the given Type B Tympanogram. The surgical management
image shows the audiogram of patient. What will be the finding of would need adenoidectomy with myringotomy/grommet insertion.
Rinne and Weber test in this patient: (INI-CET NOV 2022)
13. Arrange in sequence the pathway of production of OAE.
(INI-CET NOV 2022)
1. Outer hair cells 2. Basilar membrane
3. Ossicles 4. Oval window
5. Tympanic membrane 6. Perilymph
a. 1, 2, 3, 4, 5, 6 b. 5, 3, 4, 6, 2, 1
c. 5, 3, 4, 2, 6, 1 d. 5, 3, 4, 6, 1, 2
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 32]

Explanation: The otoacoustic emissions are produced by outer hair


cells of cochlea once sound energy stimulates them. The pathway for
the sound energy will be Tympanic membrane, ossicles, oval window,
perilymph, basilar membrane to outer hair cells.
14. Which of the following is the appropriate match for various types
of Wallerstein tympanoplasty? (INI-CET MAY 2022)
a. Type 1 Tympanoplasty 1. Placing the graft on the incus
b. Type 2 Tympanoplasty 2. Placing the graft on the
a. Right Rinnes negative, Weber lateralized to right ear footplate of the stapes
b. Left Rinnes positive, Weber lateralized to left ear c. Type 3 Tympanoplasty 3. Placing the graft on head of the
c. Right Rinnes positive, Weber lateralized to left ear stapes
d. Left Rinnes positive, Weber lateralized to right ear
d. Type 4 Tympanoplasty 4. Placing the graft on the malleus
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 26] a. a-4, b-1, c-3, d-2 b. a-3, b-2, c-4, d-1
c. a-4, b-3, c-1, d-2 d. a-2, b-1, c-3, d-4
Explanation: As per the given audiogram, patient is suffering from left  [Ref: Diseases of Ear, Nose and Throat and
sided SNHL and right has normal hearing. Neck Surgery by PL Dhingra, 8th ed., p. 473]
Left ear is the poor ear. Hence, on left side Rinne should be positive
(SNHL) and Weber should be lateralized to right ear (better ear). Explanation: Type 3 Tympanoplasty is also called Columella
12. A 6-year-old child has presented with hearing loss. On Tympanoplasty or Myringostapediopexy. Type 4 has round window
examination, there was high-arched palate with crowding of upper shielding effect.
teeth. Tympanometry was done and the image of tympanogram is 15. An image of tympanic membrane is given
shown. Which of the following surgeries may be required in this with retraction pocket. What is the grade
patient? (INI-CET NOV 2022) of the retraction pocket?
(INI-CET MAY 2022)
a. Tos Grade I
b. Tos Grade II
c. Sade Grade III
d. Sade Grade II
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 66]

Explanation:
Grade (Tos) Description
Grade 1 Mild retraction of attic, not touching the neck of malleus
Grade 2 Touching the neck of malleus
OTOLARYNGOLOGY

Grade 3 Limited erosion of outer attic wall


Grade 4 Severe erosion of outer attic wall

a. Myringotomy with grommet insertion


b. Tympanoplasty ANSWER KEY
c. Grommet insertion with adenoidectomy 11. d 12. c 13. b 14. a 15. a
d. Adenoidectomy
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 77]
714 MCQs

349. A 27-year-old patient presents to ENT OPD with the complaint of 352. A 50-year-old male patient has presented with left sided unilateral
headache and nasal blockage. The nasal endoscopy shows bilateral nasal mass and epistaxis. The radiological picture is given in the
nasal polypi. The chest examination shows bilateral auscultatory image. What is the most probable diagnosis?(INI-CET NOV 2021)
wheezing. Which drug should this patient avoid? (NEET PG 2022)
a. Gentamicin
b. Aspirin
c. Cetirizine
d. All of these
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 201-204, 203]

Explanation: It is Sampter’s triad


350. A 49-year-old diabetic patient previously treated for COVID-19
few days ago presented with complaints of nasal obstruction,
loosening of upper teeth and hemifacial pain. Which of the
following tests is to be done on priority basis? (NEET PG 2022)
a. Nasal swab for mucor
b. Serum ferritin
c. MRI nose and orbit with contrast
d. CECT nose and PNS a. Juvenile nasopharyngeal angiofibroma
b. Inverted papilloma
 [Ref: Diseases of Ear, Nose and Throat and
c. Maxillary carcinoma
Neck Surgery by PL Dhingra, 8th ed., p. 100]
d. Antrochoanal polyp
351. Which ethmoid air cell has been marked with red star in the given  [Ref: Diseases of Ear, Nose and Throat and
CT scan image? (INI-CET NOV 2021) Neck Surgery by PL Dhingra, 8th ed., p. 236, 237f, 524]

353. Identify the marked structure in the given CT scan.


(INI-CET NOV 2021)

a. Onodi cell
b. Haller’s cell
c. Concha bullosa
d. Agger nasi a. Pneumatized superior turbinate
b. Agger nasi
 [Ref: Diseases of Ear, Nose and Throat and c. Concha bullosa
Neck Surgery by PL Dhingra, 8th ed., p. 159] d. Onodi cell
OTOLARYNGOLOGY

Explanation: Onodi cell is in close relation to optic nerve. It is visible in  [Ref: Diseases of Ear, Nose and Throat and
roof of sphenoid sinus. Neck Surgery by PL Dhingra, 8th ed., p. 157]

354. Which of the following is not an olfactory test?


(INI-CET NOV 2021)
a. Arnold-stick test
ANSWER KEY b. CCSIT
c. UPSIT
349. b 350. c 351. a 352. b 353. a 354. a
d. Smell diskettes
 [Ref: Diseases of Ear, Nose and Throat and
Neck Surgery by PL Dhingra, 8th ed., p. 63]
Ophthalmology
O phthalmology
— Dr Utsav Bansal

SYNOPSIS

ANATOMY OF EYE

EMBRYOLOGY OF EYE
Various structures in the eye are formed from different germ layers as given:

Surface ectoderm Neuroectoderm Neural crest cells Mesoderm


Skin of the eyelids Optic nerve Melanocytes Extraocular muscles - 7
Epithelium of conjunctiva Retina Q
Sclera Q
Connective tissue
Epithelium of cornea Part of secondary vitreous Ciliary muscle Q
Temporal part of Sclera
Tarsal glands Epithelium of ciliary body Stroma of iris and ciliary body Endothelial lining of blood vessels
Lacrimal gland Epithelium of iris Sheaths of the optic nerve
Crystalline lens Q
Smooth muscles of iris – dilator and
Q
Bowman layer, stroma, des­cemet
sphincter pupillae membrane of cornea
Trabecular meshwork

y Development of eye begins at the end of 3rd week of gestation, y Lens is formed by the lens placode and the lens vesicle
around Day 22 y Mesenchyme derived from neural crest differentiates into a
y Retina develops from the optic cup – Outer layer of cup forms the superficial fibrous layer forming sclera and cornea and deep vascular
outermost layer of retina – Pigment epithelium and inner layer of layer forming the Uveal tract
optic cup forms the Neurosensory retina y Tunica vasculosa lentis – gives nourishment to lens during
y Anterior end of the optic cup differentiates into epithelium of iris development.
and ciliary body and the smooth muscles of iris
766 SYNOPSIS

Recti Superior oblique (SO) Inferior oblique (IO)


Nerve SupplyQ SRQ Trochlear (IV)Q nerve Oculomotor (III) nerveQ
MRQ – Oculomotor (III) nerve
IRQ
LR – AbducensQ (VI) nerve
Anato­mically • MR is susceptible to injury during • The longestQ and the thinnest • The shortest tendon
significant points anterior segment procedures EOM • The shortest EOMQ
• LR originates by 2 heads • Trochlea is the FUNCTIONAL origin • Related to inferior vortex vein near its
• SR and MR are attached to the • Only muscle to be innervated on insertion
dural sheath of optic nerve at the outer surface of belly
origin

Retrobulbar anesthetic block is not


Leads to pain on upward and effective
inward movement of the eyeball in
RETROBULBAR neuritis

Recti: Tendon width and insertions in


relation to limbus (all distances in mm)

SLIM – S > L > I > M

Actions of Extraocular Muscles


Actions of Extraocular Muscles in Primary Position
1° (Primary) 2° (Secondary) 3° (Tertiary)
MR ADDuction
LR ABDuction
SR Elevation INtorsion ADDuction
IR Depression EXtorsion ADDuction
• Pure/maximum in 23° abduction • Pure/maximum in 67° adduction
SO Q
INtorsion Q
DepressionQ ABDuctionQ

IO EXtorsionQ ElevationQ ABDuction


• Pure/maximum in 51° abduction • Pure/maximum in 39° adduction
• By anterior fibers of both obliques • By posterior fibers of both obliques

1° actions of superior and inferior muscles more in 2° actions of superior and inferior muscles more in
OPHTHALMOLOGY

ABduction ADduction

Mnemonic:
ABO SIN
AB : ABduction by S : Superior muscles
O : Obliques IN : INtorters
TEN into TEN 767

Actions of extraocular muscles

Extra Mile

Tests for Stereopsis


• The two pencil test - for gross stereopsis
• Synoptophore
• Titmus fly stereo test uses 3D polaroid vectographic pictures
• Random Dot Stereogram Test
 It eliminates use of mono-ocular clues to depth perception
 Better test than titmus fly
 Examples are as follows (see the images):

Titmus fly stereo test

TNO test Frisby test


OPHTHALMOLOGY

Lang test Frisby Davis distance (FD2) Test


Ophthalmology
Dr Utsav Bansal

ANATOMY AND PHYSIOLOGY OF EYE


[Total Questions 5]

1. Which of the following occurs when retina is exposed to light? 4. A junior researcher is studying the visual pathway and the neurons
 (INI-CET NOV 2022) involved in it. Which of the following is the third-order neuron in
a. Depolarization, increase in neurotransmitter release the optic pathway? New Qs

b. Depolarization, decrease in neurotransmitter release a. Photoreceptor cell


c. Hyperpolarization, increase in neurotransmitter release b. Bipolar cell
d. Hyperpolarization, decrease in neurotransmitter release c. Ganglion cell
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 20-21] d. Lateral geniculate nucleus (LGN)
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 28-29]
2. A man suffers blunt trauma to the eye following which he has
dislocation of the lens. The lens is embryologically derived from Explanation: The optic pathway consists of a series of neurons that
which of the following structure? New Qs transmit visual information from the retina to the brain.
a. Neuroectoderm The photoreceptor cells, specifically the rods and cones, are the
b. Surface ectoderm first-order neurons in the optic pathway. They convert light signals into
c. Mesoderm electrical signals and transmit them to the second-order neurons, which
d. All of these are the bipolar cells.
The bipolar cells receive input from the photoreceptor cells and relay
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 7]
the signals to the third-order neurons, which are the ganglion cells.
Explanation: The lens is derived from the surface ectoderm; thus option Ganglion cells are located in the innermost layer of the retina and
B is correct. their axons form the optic nerve. These ganglion cells carry the visual
The surface ectoderm thickens at a specific point to form the lens information from the retina to the brain.
placode. The lens placode invaginates inside, and forms the lens pit and y Photoreceptor cell is the first-order neuron
subsequently the lens vesicle. This vesicle is responsible for development y Bipolar cell is the second-order neuron
of lens. On day 33 of intrauterine life, the lens vesicle separates from the y Lateral geniculate nucleus (LGN) is the fourth-order neuron.
surface ectoderm and lies close to the optic cup. 5. Match the following structures of eye with their embryological
Neuroectoderm: It forms the optic cup and its derivatives like the retina,
derivatives. New Qs
pigment epithelium of the choroid or ciliary body, secondary and tertiary
vitreous, etc. Column-A Column-B
Mesoderm: It forms the primary vitreous and other structures like 1. Neural ectoderm a. Temporal part of the sclera
choriocapillaris, extraocular tissue, vascular endothelium, etc. 2. Mesoderm b. Crystalline lens
3. A 10-year-old patient has been diagnosed with iris coloboma 3. Neural crest c. Retina
during routine ocular examination. What is the embryonic origin 4. Surface ectoderm d. Ciliary muscle
of uveal tissue? New Qs a. 1-a, 2-b, 3-c, 4-d b. 1-c, 2-a, 3-d, 4-b
a. Mesoderm b. Ectoderm c. 1-c, 2-a, 3-b, 4-d d. 1-d, 2-c, 3-b, 4-a
c. Endoderm d. Neural crest  [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 4]
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 4]

Explanation: The uveal tissue, which includes the iris, ciliary body,
and choroid, has its embryonic origin from the neural crest. The neural
crest is a group of cells that arise from the neural tube during embryonic
development and give rise to various structures in the body, including the ANSWER KEY
uveal tissue of the eye. 1. d 2. b 3. d 4. c 5. b
Ectoderm gives rise to conjunctiva, cornea and lens.
Endoderm does not play a role in the development of eye.
TEN into TEN 813

Explanation: The given image is a Sturm’s conoid. Configuration of Explanation: Applanation tonometer is used to measure IOP. It is based
rays refracted through a toric (regularly astigmatic) surface is known as on Imbert-Fick law, which states that the pressure inside an ideal dry, thin
Sturm’s conoid. walled sphere equals the force necessary to flatten its surface divided by
Astigmatism is a refractive error in which the refraction varies in the area of the flattening.
different meridians of eye, due to which light rays fail to converge in a P = F/A
point focus. Tangent screen used at 1 or 2 meters, it should have a uniform illumination
of 7 foot-candles and it should be large enough to allow testing of the full
8. A 70-year-old patient presents with distant visual acuity of 6/18 30° of central field.
which improved on pin hole testing. He gives history of not
needing glasses for near vision now. On ocular examination 10. A patient has presented for a routine eye evaluation. You have
findings as shown in image were seen. Patient has which of the checked visual acuity on Snellen chart and found it to be 6/6. What
following refractory error. (NEET PG 2023) is the minimum angle of resolution? (INI-CET NOV 2022)
a. 15 minutes of arc b. 5 minutes of arc
c. 10 minutes of arc d. 20 minutes of arc
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 84-89]

Explanation: Snellen chart consists of letters arranged in lines, with


progressively diminishing size. Each letter subtends an angle of 5 minutes
at the nodal point of eye when viewed from its respective distances. Each
letter is so constructed that the width (of each stroke) subtends an angle
of 1 minute = MAR
Normal visual acuity for far is 6/5
Best visual acuity for far is 6/3
Minimum recordable visual acuity on Snellen’s chart is 1/60

a. Axial myopia b. Curvatural myopia


c. Positional myopia d. Index myopia
 [Ref: Parsons’ Diseases of the Eye, 23rd ed., p. 64]

Explanation: The most likely diagnosis based on the given clinical


scenario and the image is index myopia seen in nuclear senile cataract.
Axial (MC Curvatural Positional Index
Type)

Axial length of Curvature of cornea Position of Refractive index


eye or lens lens of lens
↓ ↓ ↓ ↓
1 mm ↑ = 3 D As curvature Moves Increases
myopia increases, so, anteriorly
radius of curvature
decreases 1 mm ↓
= 6 D myopia

Associated with May be due to Due to Seen in Nuclear


precocious Keratoconus, anterior cataract due to
growth in Lenticonus or subluxation Sclerosis
children Spherophakia of lens
causing simple/ (as seen
school going in Weill-
myopia and Marchesani
buphthalmos syndrome)
(congenital
glaucoma) 11. A 15-year-old female with myopic astigmatism refuses to wear
glasses; what would be the ideal management? (NEET PG 2021)
OPHTHALMOLOGY

9. Match the following (INI-CET NOV 2022) a. LASIK b. Femto LASIK


1. Color vision a. Applanation tonometer c. ICL d. Spherical equivalent glasses
2. IOP b. Ishihara chart  [Ref: Ophthalmology by Yanoff and Duker, 5th ed., p. 41]

3. Peripheral vision c. Tangent screen test


4. Central vision d. Perimetry ANSWER KEY
a. 1-b, 2-a, 3-d, 4-c b. 1-d, 2-b, 3-a, 4-c 8. d 9. a 10. b 11. d
c. 1-d, 2-c, 3-a, 4-b d. 1-a, 2-c, 3-d, 4-b
 [Ref: Parsons’ Diseases of Eye, 23rd ed., p. 97, 108]
844 MCQs

142. A 57-year-old man is brought to the emergency department following a generalized tonic-clonic seizure.
His wife reports that he has no history of seizures. However, she says that he has been complaining of
intermittent headaches, memory loss, and problems with his vision for the past 2 weeks. Brain imaging
shows a solitary mass within the right temporal lobe. Which of the following visual field defects given in
the image is most likely present in this patient? New Qs

a. C b. B
c. A d. D
 [Ref: Kanski, 9th ed., p. 786]

Explanation:
Damage to the visual pathway produces distinct types of visual field defects depending on the location of the lesion. Visual perception begins with
light from the nasal visual fields striking the temporal side of each retina and light from the temporal visual fields striking the nasal side of each retina.
Information from the retina is then transmitted by the optic nerves to the optic chiasm. At the optic chiasm, optic nerve fibers from the nasal half of each
retina cross and project into the contralateral optic tract.
In contrast, nerve fibers from the temporal parts pass into the ipsilateral optic tract. The optic tract thus contains nerve fibers from the temporal part
of the ipsilateral retina and the nasal part of the contralateral retina. Optic tract fibers project mainly to the lateral geniculate nucleus (LGN), but also
project to superior colliculus (reflex gaze), pretectal area (light reflex), and the suprachiasmatic nucleus (circadian rhythms).
Axons from the LGN that project to the striate (primary visual) cortex are known as the optic radiation (or geniculocalcarine tract). The lower fibers of
the optic radiation carry information from the lower retina (upper contralateral visual field) and take a circuitous route anteriorly into the temporal lobe
(Meyer’s loop) before reaching the lingual gyrus of the striate cortex. The upper fibers of the optic radiation carry information from the upper retina (lower
contralateral visual field) and pass more directly from the LGN Reverse Color through the parietal lobe to reach the cuneus gyrus of the striate cortex.
OPHTHALMOLOGY

Lesions in the temporal lobe can disrupt Meyer’s loop and produce a contralateral superior quadrantanopia. Temporal lobe lesions can also produce
other neurologic manifestations, including aphasia (dominant hemisphere lesions), memory deficits, seizures (complex partial and tonic-clonic), and
hallucinations (auditory, olfactory, and visual).

ANSWER KEY
142. a
Creating your own mnemonics for eye muscle functions and nerve
innervations can help you re-member tricky anatomy details more easily.
846 MCQs

Explanation: The given clinical scenario and the given image are 146. Which of the following is not a feature of complicated cataract?
suggestive of an immature senile cataract and the management of this  (INI-CET NOV 2022)
condition is phacoemulsification + posterior IOL implantation. a. Polychromatic luster b. Occurs after uveitis
Types of Cataract c. Krukenberg spindle d. Breadcrumb app
 [Ref: Kanski’s Clinical Ophthalmology, 9th ed., p. 381]

Explanation: Krukenberg’s spindle (Pigment is deposited on the


endothelium in a vertical spindle shape) is a feature of pigmented
glaucoma not a features of complicated cataract.
Complicated cataract occurs due to disturbances of lens nutrition
secondary to chronic anterior uveitis (most common), high myopia,
angle closure glaucoma and fundus dystrophies like retinitis pigmentosa.
Polychromatic crystals in Snowflake cataract: Diabetes Cataract occurs as posterior cortical atrophy in the axial region near
a Christmas tree pattern: mellitus the nodal point.
Myotonic dystrophy Present as posterior cortical/posterior subcapsular cataract.
Complicated cataract having breadcrumb appearance with
polychromatic luster.

147. Identify the step which is given in the image.


 (INI-CET NOV 2021)

Oil Droplet cataract: Shield cataract (anterior


Galactosemia subcapsular cataract): Atopic
dermatitis

a. Capsulorhexis b. IOL implantation


c. Hydrodissection d. Lens aspiration
Rosette cataract: Blunt trauma Sunflower cataract: Chalcosis/
Wilson’s disease  [Ref: Kanski’s Clinical Ophthalmology, 9th ed.,
p. 323-326]

Explanation:
Capsulorhexis is the step shown in the given image.
Capsulorhexis is a method of anterior capsulotomy, where an opening
is made in the anterior capsule of the lens. It is one of the steps involved
in conventional extracapsular cataract extraction (ECCE).
Anterior capsulotomy can be done by one of three methods—
can-opener technique, linear capsulotomy or envelope technique, or
Glassblowers cataract: Infrared Congenital lamellar (zonular)
continuous curvilinear capsulorhexis.
radiation cataract: Hypoparathyroidism
Continuous curvilinear capsulorhexis (CCC), is considered to be
(Hypocalcemia) and
superior to all the preexisting methods because when done correctly, it
Hypovitaminosis D
does not leave any edges or tears. Trypan blue dye can be used to stain the
lens capsule for better visibility.
Hydrodissection is performed to separate the nucleus and cortex
from the capsule so that the nucleus can be manipulated. A blunt cannula
is inserted just beneath the edge of the capsulorhexis and fluid injected
OPHTHALMOLOGY

gently under the capsule.

Nuclear cataract: Congenital rubella

ANSWER KEY
146. c 147. a
2 VOLUME SET
PART – B

SUBJECTS COVERED

PEDIATRICS SURGERY
07 Dr Anand Bhatia
09 Dr Rohan Khandelwal

MEDICINE OBSTETRICS AND GYNECOLOGY


08 Dr Mohammed Shakeel Sillat
10 Dr Sakshi Arora Hans

EDITED BY

Dr Sudhir Kumar Singh

CBS Publishers & Distributors Pvt Ltd


• New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai
• Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand
Contents

Preface ............................................................................................................................................................................................................................................... iii


Acknowledgments ............................................................................................................................................................................................................................. iv
Special Features of the Book .............................................................................................................................................................................................................. v
Detailed Table of Contents ....................................................................................................................................................................................................... xi–xvi
[Subject-wise cum Topic-wise Questions]
Most Recent Questions ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� xvii–lxxx
[NEET PG 2024 and INI-CET MAY 2024]

PEDIATRICS 933–1172
Dr Anand Bhatia
Synopsis �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 933–954
Multiple Choice Questions ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 955–1172

MEDICINE  1173–1364
Dr Mohammed Shakeel Sillat
Synopsis ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1173–1207
Multiple Choice Questions ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1209–1364

SURGERY 1365–1576
Dr Rohan Khandelwal
Synopsis ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1365–1433
Multiple Choice Questions ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1435–1576

OBSTETRICS AND GYNECOLOGY 1577–1780


Dr Sakshi Arora Hans
Synopsis ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1577–1622
Multiple Choice Questions ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1623–1780
Detailed Table of Contents
[Subject-wise cum Topic-wise Questions]

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

PEDIATRICS
1. Growth and Development 6 47 104 157

2. Nutrition and Malnutrition 20 20 57 97

3. Genetic Disorder 12 8 27 47

4. Neonatology 27 51 96 174

5. Infectious Disease and Immunization 21 2 136 159

6. Inborn Errors of Metabolism 7 14 40 61

7. Fluids and Electrolytes 2 12 11 25

8. Hematology 9 1 10 20

9. Tumors/Oncology 0 0 10 10

10. Cardiology 15 3 53 71

11. Pulmonology 13 7 56 76

12. Gastroenterology 4 3 45 52

13. Hepatology 2 0 5 7

14. Renal and Genitourinary/Nephrology 7 6 29 42

15. Neurology 12 26 75 113

16. Endocrinology 3 3 15 21

17. Vaccine 13 13 19 45

18. Musculoskeletal System 0 0 14 14

Total Qs 173 216 802 1191

MEDICINE
1. General Medicine 61 18 25 104

Acid-Base Disorders 17 10 7 34

Fluids and Electrolytes Imbalance 15 4 16 35

Disorders of Temperature Regulation 1 3 1 5

Critical Care and Emergency Medicine 13 1 1 15

Toxicology 9 0 0 9

Nutrition 3 0 0 3

Miscellaneous 3 0 0 3
xii Detailed Table of Contents

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

2. Infectious Diseases 82 36 23 141

Acute Febrile Illnesses 10 10 1 21

HIV Infection and Aids 13 4 5 22

Tuberculosis 4 6 3 13

COVID-19 10 1 0 11

Infections of the CNS 7 1 1 9

Pulmonary Infections 6 0 1 7

Acute Rheumatic Fever and Infective 7 3 1 11


Endocarditis

Viral Hepatitis 10 3 9 22

Intra-Abdominal and Entericinfections 5 3 2 10

Genitourinary Tract Infections 2 0 0 2

Miscellaneous 8 5 0 13

3. Neurology 69 33 53 155

Neurological Examination 5 3 2 10

Primary Headache 4 2 1 7

Seizures and Epilepsy 3 0 7 10

Cerebrovascular Diseases 17 8 17 42

Dementia 5 0 2 7

Parkinson’s Disease 2 3 1 6

Movement Disorders 3 0 3 6

Demyelinating Disorders of the CNS 4 2 3 9

Motor Neuron Diseases 2 4 0 6

Ataxic Disorders 0 2 1 3

Cranial Nerve Disorders 3 0 0 3

Diseases of the Spinal Cord 10 0 2 12


Detailed Table of Contents

Peripheral Neuropathy 0 0 2 2

Immune Mediated Neuropathies 3 4 3 10

Diseases of the Neuromuscular Junction 5 5 4 14

Myopathies and Muscular Dystrophies 0 0 2 2

Miscellaneous 3 0 3 6

4. Cardiovascular System 64 31 57 152

Physical Examination 13 0 11 24

Electrocardiography 7 9 16 32

Bradyarrhythmias 1 0 1 2

Tachyarrhythmias 11 2 7 20
TEN into TEN xiii

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

Heart Failure 7 1 0 8

Cardiomyopathy and Myocarditis 3 1 7 11

Valvular Heart Diseases 5 1 2 8

Congenital Heart Diseases in the Adults 2 1 0 3

Pericardial Diseases 0 3 1 4

Ischemic Heart Disease 1 2 1 4

Acute Coronary Syndrome 5 8 6 19

Hypertension and Renovascular Diseases 6 0 1 7

Diseases of the Aorta 2 1 3 6

Miscellaneous 1 2 1 4

5. Respiratory System 23 29 43 95

Pulmonary Function Testing 7 5 2 14

Obstructive Airway Diseases 4 12 8 24

Interstitial Lung Diseases and Hypersensitivity 1 4 5 10


Pneumonitis

Cystic Fibrosis 2 0 3 5

Occupational and Environmental Lung 2 0 1 3


Diseases

Ards and Respiratory Failure 1 2 5 8

Diseases of the Pleura and Mediastinum 3 1 5 9

DVT and Pulmonary Embolism 2 2 5 9

Pulmonary Hypertension 1 3 0 4

Sleep Apnea and Hypoventilation Syndromes 0 0 5 5

Miscellaneous 0 0 4 4

6. Gastrointestinal System 6 28 38 72

Diseases of the Esophagus 0 11 11 22

Peptic Ulcer Disease 2 3 7 12

Malabsorption Syndromes 2 3 8 13 Detailed Table of Contents


Acute and Chronic Diarrhea 0 0 3 3

Inflammatory Bowel Disease 2 9 8 19

Irritable Bowel Syndrome 0 2 1 3

7. Hepatobiliary System 9 22 35 66

Evaluation of Liver Function 3 1 3 7

Bilirubin Metabolism and Hyperbilirubinemia 0 0 3 3

Toxin and Autoimmune Hepatitis 0 2 5 7

Alcoholic and Nonalcoholic Liver Diseases 1 3 2 6


xiv Detailed Table of Contents

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

Cirrhosis and its Complications 4 10 14 28

Liver Transplantation 1 0 1 2

Acute and Chronic Pancreatitis 0 3 4 7

Miscellaneous 3 3 6

8. Nephrology 15 30 51 96

Urinary Abnormalities 1 2 2 5

Acute Kidney Injury 0 0 2 2

Chronic Kidney Diseases 2 1 2 5

Dialysis and Transplantation 1 0 7 8

Glomerular Syndromes 7 14 27 48

Polycystic Kidney Diseases and Tubular 0 3 4 7


Diseases

Tubulointerstitial Diseases 0 2 3 5

Nephrolithiasis 1 3 0 4

Hereditary Nephropathies 2 5 4 11

Miscellaneous 1 0 0 1

9. Endocrinology and Metabolism 43 28 57 128

Pituitary and Hypothalamus 8 4 13 25

Thyroid Gland 6 2 13 21

Parathyroid Gland 1 2 2 5

Adrenal Cortex 3 6 5 14

Pheochromocytoma and Polyglandular 2 2 7 11


Syndromes

Diabetes Mellitus 12 4 6 22

Obesity and Metabolic Syndromes 6 0 0 6

Metabolic Bone Diseases 2 2 0 4

Metabolic Disorders 3 6 7 16
Detailed Table of Contents

Miscellaneous 0 0 4 4

10. Hematology 59 25 79 163

Hypoproliferative Anemia 11 0 2 13

Hemoglobinopathies 5 2 5 12

Macrocytic Anemia 3 0 3 6

Hemolytic Anemia 5 3 8 16

Bone Marrow Failure Syndromes 4 4 5 13

Myeloproliferative Neoplasms 0 3 7 10

Acute and Chronic Leukemia 11 11 10 32


TEN into TEN xv

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

Hodgkin and Non-Hodgkin Lymphoma 6 2 15 23

Plasma Cell Disorders 4 0 6 10

Transfusion Medicine 2 0 6 8

Disorders of Hemostasis 6 0 10 16

Miscellaneous 2 0 2 4

11. Rheumatology 31 21 34 86

Rheumatoid Arthritis and Osteoarthritis 5 4 9 18

Crystal Associated Arthropathies 2 0 7 9

Axial and Peripheral Spondyloarthritis 3 5 1 9

Systemic Lupus Erythematosus and 4 0 6 10


Antiphospholipid Syndrome

Systemic Sclerosis and Sjögren Syndrome 3 3 1 7

Inflammatory Myopathies 1 3 0 4

Vasculitis Syndromes 6 1 6 13

Sarcoidosis 3 4 2 9

Miscellaneous 4 1 2 7

Total Qs 462 301 495 1258

SURGERY
1. General Surgery 28 21 87 136

2. Trauma 32 25 58 115

3. Oral Cavity and Malignancy 14 20 35 69

4. Thyroid 18 19 18 55

5. Breast 23 20 43 86

6. Hernia 10 15 21 46

7. Gastrointestinal Tract 55 40 37 132

8. Hepatology 43 15 24 82

Detailed Table of Contents


9. Urology 41 15 17 73

10. Cardiothoracic Vascular Surgery 27 20 54 101

11. Plastic Surgery 3 25 26 54

12. Endocrine Surgery 7 21 3 31

13. Pediatric Surgery 1 9 22 32

14. Neurosurgery 7 10 21 38

15. Oncosurgery 6 10 22 38

16. Transplant Surgery 3 15 20 38

17. Miscellaneous 0 15 6 21

Total Qs 318 315 514 1147


xvi Detailed Table of Contents

Sl. no. Subjects Covered 5 Years Recall Qs Frequently asked Qs New Qs Total Qs

OBSTETRICS AND GYNECOLOGY


1. Obstetrics 160 166 200 526

Anatomy and Physiology of Reproductive 14 11 14 39


Organs

Placenta Physiology and Amniotic Fluid 5 7 16 28

Diagnosis of Pregnancy 10 17 8 35

Antenatal Assessment and Fetal Well-Being 17 19 18 54

Obstetric Complications in Pregnancy 23 24 25 72

Medical and Surgical Disorder in Pregnancy 32 13 28 73

Infection in Pregnancy 8 4 11 23

Drug, Vaccine and Teratogens in Pregnancy 4 8 8 20

Fetal Skull and Maternal Pelvis 4 18 9 31

Normal and Abnormal Labor 37 24 45 106

Normal and Abnormal Puerperium 3 17 7 27

Miscellaneous Topics 3 4 11 18

2. Gynecology 124 107 220 451

Disorders of Menstruation 25 20 44 89

Common Conditions in Gynecology 27 28 48 103

Benign Conditions in Gynecology 23 13 25 61

Infections in Gynecology 12 15 33 60

Urinary and Intestinal Tract in Gynecology 2 4 8 14

Gynecological Malignancies 25 26 51 102

Imaging Modalities, Endoscopic 10 1 11 22


Procedures and Major and Minor
Operations in Gynecology

Total Qs 284 273 420 977


Detailed Table of Contents

MOST RECENT QUESTIONS


[NEET PG 2024 AND INI-CET MAY 2024]

Sl. no. Subjects Covered Total Qs

7. PEDIATRICS 40

8. MEDICINE 92

9. SURGERY 60

10. OBSTETRICS AND GYNECOLOGY 61


Most Recent Questions
[NEET PG 2024 and INI-CET MAY 2024]

PEDIATRICS
Explanation:
NEET PG 2024

1. A 3-month-old baby is brought with intracranial diffuse


calcifications, chorioretinitis and hydrocephalus. What is the
most likely diagnosis?

4. A 1-month-old baby with olive shape mass and recurrent vomiting.


USG was done which is shown below. What is your diagnosis?

a. Toxoplasmosis b. CMV
c. Zika virus d. Rubella
 [Ref: Nelson, 21st ed., Chapter 316]
2. At what pressure, pop valve is released in bag and mask ventilation?
a. 30-40 cm of H2O b. 40-50 cm of H2O
c. 50-60 cm of H2O d. 60-70 cm of H2O
 [Ref: Nelson, 21st ed., Chapter 121]
3. Maximum lymphoid growth is seen at what age?

a. CHPS
b. Intussusception
c. Meckels diverticulum
d. None of the above
 [Ref: Nelson, 21st ed., Chapter 355]

ANSWER KEY
PEDIATRICS
a. 2 years b. 6 years
1. a 2. a 3. b 4. a
c. 10 years d. 14 years
 [Ref: Nelson, 21st ed., Chapter 20]
P ediatrics

Pediatrics
— Dr Anand Bhatia

SYNOPSIS

RATES OF GROWTH OF DIFFERENT TISSUES MANAGEMENT OF STATUS EPILEPTICUS


AND ORGANS
Following initial assessment, patients need to be treated with
anticonvulsants. If required, more than one agent may be administered
sequentially. Patients should be monitored for respiratory difficulty and
might need assisted ventilation.
TEN into TEN 935

SEXUAL MATURITY RATING (1–5) IN GIRLS SEXUAL MATURITY RATING (1–5) IN BOYS

MAINTENANCE FLUID REQUIREMENT IN HEALTHY CHILDREN

Body weight Per day Per hour


0–10 kg 100 mL/kg 4 mL/kg
10–20 kg 1000 mL for first 10 kg + 50 mL/kg for each kg beyond 10 kg 40 mL + 2 mL/kg for each kg beyond 10 kg
>20 kg 1500 mL + 20 mL/kg for each kg beyond 20 kg 60 mL + 1 mL/kg for each kg beyond 20 kg

CLINICAL ASSESSMENT OF DEHYDRATION

Assessed for No dehydration Some dehydration Severe dehydration


Decrease in body weight <5% in infants; 5–10% in infants; >10% in infants;
<3% in older children 3–6% in older children >6% in older children
PEDIATRICS

Mental status Normal Irritable Lethargic to comatose


Thirst Normal Increased Unable to drink
Skin color and elasticity (turgor) Normal Cool, pale; mild delay in turgor Cold, mottled; tenting
Contd...
Pediatrics
Dr Anand Bhatia

GROWTH AND DEVELOPMENT


[Total Questions 157]

1. HEADSS is used for: (INI-CET NOV 2023) 8. A child came to the emergency with a history of ingestion of button
a. Infants b. 0–5 years battery, on X-ray it was found in the stomach. What is the next step?
c. 5–10 years d. Adolescents a. Endoscopic removal of battery
 [Ref: Nelson, 21st ed., p. 820] b. Wait and watch
c. Repeat X-ray after 5 days
2. Handedness is usually determined by the age of: d. Immediate laparotomy
(INI-CET NOV 2022)  [Ref: Nelson, 21st ed., p. 2545]
a. 1 year b. 2 years
c. 3 years d. 4 years 9. Which of the following fontanel is the last to close?
 [Ref: Nelson, 21st ed., p. 1157] a. Posterior fontanel normally
b. Anterior fontanel
3. Alternate way to measure height in a 4-year-old child is: c. Mastoid fontanel
(INI-CET NOV 2022) d. Sphenoidal fontanel
a. Head circumference b. Knee height  [Ref: Nelson, 21st ed., p. 3766]
c. Crown-rump length d. Arm span
 [Ref: Nelson, 21st ed., p. 1183] 10. The milestones of a 3-year-old child are considered delayed if he
is unable to:
4. Method of measurement of height in 4 years: (INI-CET NOV 2022) a. Hop on one foot b. Use spoon effectively
a. Infantometer b. Stadiometer c. Copy a square d. Reliably catch a ball
c. Harpenden caliper d. None of these  [Ref: Nelson, 21st ed., p. 1124]
 [Ref: Nelson, 21st ed., p. 1182]
11. What is the drug of choice for precocious puberty in girls?
5. Match the following according to the developmental milestones of a. GnRH analogs
different age group of infants:(INI-CET NOV 2021) b. Cyproterone acetate
1. Social smile A. 1–2 months c. Danazol
d. Medroxyprogesterone acetate
2. Pincer grasp B. 5–6 months
 [Ref: Nelson, 21st ed., p. 11359]
3. Walks 1–2 steps C. 9–1 months
12. A 6-year-old male child comes with complaints of bedwetting.
4. Transfer objects D. 12–13 months
The child is continent during the day and the problem is only at
a. 1A 2C 3D 4B b. 1C 2A 3D 4B night. Growth and development of the child were normal. Urine
c. 1A 2C 3B 4D d. 1B 2A 3C 4D microscopy is normal and urine specific gravity is 1.020. How will
 [Ref: Nelson, 21st ed., p. 22] you manage?
a. Reassure the parents and follow-up after 6 months
6. Bidextrous grip is seen at what age? (NEET PG 2019) b. Refer to psychiatrist
a. 4 months b. 5 months c. Complete blood counts
c. 6 months d. 7 months d. Ultrasound–KUB
 [Ref: Nelson, 21st ed., p. 1105]  [Ref: Nelson, 21st ed., p. 11044]
7. Which of the following is considered developmental delay in a
3-year-old child?
a. Unable to copy square
b. Unable to use spoon ANSWER KEY
c. Unable to hop on one foot 1. d 2. c 3. d 4. b 5. a 6. a
d. Unable to catch ball properly 7. b 8. a 9. b 10. b 11. a 12. a
 [Ref: Nelson, 21st ed., p. 1150]
958 MCQs

54. A 6-month-old infant is brought to the clinic for a routine 59. During a routine developmental assessment, a 3-year-old child’s
check-up. On examination, the head circumference is found to Gesell Developmental Schedule yields a developmental quotient
be significantly smaller than the 3rd percentile, while the height (DQ) of 100. What is the most appropriate interpretation of this
and weight are at the 50th percentile. The infant demonstrates finding? New Qs

irritability and increased muscle tone. Which of the following a. Normal development b. Mild developmental delay
conditions is most likely associated with these clinical findings? c. Borderline development d. Advanced development
a. Microcephaly b. Hydrocephalus New Qs
 [Ref: Nelson, 21st ed., p. 1869]
c. Down syndrome d. Prader-Willi syndrome
 [Ref: Nelson, 21st ed., p. 1695] 60. A 4-year-old boy is brought to the pediatrician for a routine check-up.
On examination, his height is noted to have doubled since birth.
Explanation: Option a: The combination of a significantly small head What is the most likely interpretation of this finding? New Qs

circumference, normal height and weight, along with irritability and a. Accelerated growth requiring further investigation
increased muscle tone, is indicative of microcephaly b. Normal growth trajectory for a 4-year-old
c. Constitutional growth delay
55. A 2-month-old infant is brought to the pediatrician for a routine
d. Early onset of puberty
examination. On palpation, the physician identifies a soft spot
on the infant’s skull located at the intersection of the frontal and  [Ref: Nelson, 21st ed., p. 1870]
parietal bones. Which of the following terms best describes the 61. A 2-week-old newborn is brought for a well-baby check-up. On
precise location of this soft spot in the infant’s skull? New Qs
examination, the pediatrician notes a small, diamond-shaped
a. Bregma b. Lambda anterior fontanel. What is the most likely cause of the fontanel’s
c. Asterion d. Pterion appearance in this healthy newborn? New Qs
 [Ref: Nelson, 21st ed., p. 2551] a. Craniosynostosis b. Normal variation
c. Hydrocephalus d. Vitamin D deficiency
56. A 3-year-old boy is brought to the clinic due to concerns about
his growth and development. Physical examination reveals  [Ref: Nelson, 21st ed., p. 3766]
macrocephaly, a prominent jaw, and a pointed chin. His height
62. A 2-month-old infant is brought to the pediatrician, and the
and weight are both above the 97th percentile for his age, and he
parents express concern about the soft spot on the baby’s head. In
has advanced bone age. The child’s developmental milestones are
a newborn, how many fontanels are typically present? New Qs
appropriate for his age. Which of the following is the most likely
a. One b. Two
diagnosis? New Qs
c. Three d. Six
a. Sotos syndrome
b. Marfan syndrome  [Ref: Nelson, 21st ed., p. 3767]
c. Beckwith-Wiedemann syndrome 63. A 7-month-old infant is brought to the pediatrician, and the
d. Fragile X syndrome parents inquire about the appearance of the baby’s first teeth.
 [Ref: Nelson, 21st ed., p. 11319] Which of the following sets of temporary teeth is most likely to
have erupted or be in the process of erupting in this infant?
57. A 1-month-old infant is brought to the clinic with downward
a. Lower central incisors New Qs
slanting eyes, absence of lower eyelashes, and bilateral external
b. Upper lateral incisors
ear anomalies characterized by hypoplastic, malformed, or absent
c. Upper central incisors
pinnae. The child also has a small mandible and cleft palate.
d. Canines
Which of the following conditions is the most likely diagnosis in
this case? New Qs  [Ref: Nelson, 21st ed., p. 7593]
a. Treacher Collins syndrome 64. A 15-month-old toddler is brought to the pediatrician for a
b. Down syndrome developmental check-up. The parents express concerns about
c. Pierre Robin sequence the child’s brain development. The pediatrician explains that by
d. Turner syndrome the age of 2, approximately what percentage of the child’s brain
 [Ref: Nelson, 21st ed., p. 4222] growth is expected to be completed? New Qs

58. A pregnant woman in her first trimester with a history of neural a. 50% b. 70%
tube defects (NTDs) in a previous pregnancy is seeking guidance c. 85–90% d. 100%
on folic acid supplementation. What is the recommended daily  [Ref: Nelson, 21st ed., p. 1742]
dose of folic acid supplementation for this high-risk population?
Explanation: The correct answer is (c) 85%–90%. By the age of 2 years
a. 400 mg
b. 600 mg New Qs 65. A 9-year-old girl is referred for evaluation of short stature. Physical
c. 800 mg examination reveals normal growth parameters, and bone age
d. 4000 mg assessment indicates delayed skeletal maturation. Laboratory
 [Ref: Nelson, 21st ed., p. 1926] tests rule out endocrine abnormalities. What is the most likely
PEDIATRICS

diagnosis for this child’s short stature? New Qs

a. Growth hormone deficiency


ANSWER KEY b. Constitutional growth delay
54. a 55. a 56. a 57. a 58. d 59. a c. Turner syndrome
60. b 61. b 62. d 63. a 64. c 65. b d. Familial short stature
 [Ref: Nelson, 21st ed., p. 1192]
TEN into TEN 1019

426. You are evaluating a term newborn for respiratory distress, and you want to calculate the Silverman-Anderson score. Upon examination, the
baby exhibits the following clinical signs: just visible lower chest retractions, minimal nasal flaring, grunting with naked ear, and see saw
respiration with no xiphoid retractions. What would be the calculated Silverman-Anderson score for this newborn? New Qs

a. 0 b. 3
c. 6 d. 9
 [Ref: Nelson, 21st ed., p. 3997]

Explanation: The Silverman-Anderson score is a clinical assessment tool used to evaluate the severity of respiratory distress in newborns. It assesses
five criteria, each scored from 0 to 2: chest retractions, nasal flaring, expiratory grunting, audible wheezing, and oxygen requirement.
In this case, the baby exhibits the following clinical signs:
y Lower chest retractions: just visible (score 1)
y Minimal nasal flaring: Present (score 1)
y Grunting with naked ear: Present (score 2)
y See saw respiration: Present (score 2)
y No Xiphoid retractions: (score 0)
To calculate the Silverman-Anderson score, sum the scores for each criterion: 1 + 1 + 2 + 2 + 0 = 6.
So, the calculated Silverman-Anderson score for this newborn is: c) 6
A higher score indicates a greater severity of respiratory distress. In this case, the baby’s score of 6 suggests moderate respiratory distress.

427. In a neonatal intensive care unit, a nurse observes a newborn as 429. A term newborn is being assessed for gestational age using the
part of routine assessments and notices certain characteristics Ballard score. On examination, the baby has abundant lanugo,
related to the eyes. To better understand the normal features of smooth pink visible veins, and breast tissue barely perceptible. The
a newborn’s pupils and their implications, the nurse initiates a plantar creases are present at the entire sole, eyelids fused tightly,
discussion with colleagues. What are the distinctive characteristics testes in upper canal, rare rugae. What would be the calculated
of a newborn’s pupils? New Qs Ballard score in the physical maturity for this newborn? New Qs
a. Dilated b. Constricted a. 5 b. 7
c. Mid dilated d. Mid constricted c. 9 d. 11
 [Ref: Nelson, 21st ed., p. 10,153]  [Ref: Nelson, 21st ed., p. 3883]

428. In a neonatal intensive care unit, a premature infant is being


evaluated for suspected sepsis, and the healthcare team is
PEDIATRICS

considering laboratory markers to aid in diagnosis. Which specific


acute phase reactant serves as a valuable marker in the acute-phase
response to infection in neonates? New Qs ANSWER KEY
a. CRP b. ESR 426. c 427. b 428. a 429. a
c. WBC d. ANC
 [Ref: Nelson, 21st ed., p. 4143]
1020 MCQs

Explanation: The Ballard score is a clinical assessment tool used to estimate the gestational age of a newborn based on physical and neuromuscular
criteria. It includes two main categories: physical and neuromuscular signs.
In this case, the baby exhibits the following physical signs:
� Abundant lanugo: 1 score � Smooth pink visible veins : 1 score
� Breast tissue barely perceptible: 0 score
The neuromuscular signs are described as:
� Plantar creases at the entire sole: 4 score � Eyelids fused tightly: –2 score
� Testes in upper canal, rare rugae: 1 score
So, the calculated Ballard score for this newborn is: a 5
The Ballard score ranges from –10 to +50, with lower scores indicating a more premature infant and higher scores indicating a more mature infant.
PEDIATRICS

ANSWER KEY

While reading a topic, use a highlighter and highlight the important


words of that topic.
1022 MCQs

Other benign, transient neonatal changes seen are: Etiology: Pathologically, any factors which interfere with the circulation
y Transient neonatal pustular melanosis between maternal and fetal blood exchange.
y Erythema toxicum Pathophysiology of Asphyxia
y Breast enlargement Redistribution of blood flow to vital organs (brain, heart and adrenal) to
y Vaginal discharge prevent from hypoxic damage. ‘Diving Reflex’
y Vernix caseosa
y Caput succedaneum Features Stage I Stage II Stage III
y Epstein pearls Severity Mild degree Moderate Severe degree
y Subconjunctival hemorrhages degree
Options a, b and c are true statements regarding the Mongolian spots.
Consciousness Hyper alert and Lethargic and Comatosed
440. A mother brings her 5-day-old neonate with the appearance of irritable obtunded
the following rash on day 3 of life. On examination the child was
alert and active. There were no other significant clinical sign or Pupils Dilated Constricted Dilated
symptom noted in the child. Based on the clinical history and
Tone Normal tone Marked Flaccidity
findings given, identify the condition diagnosis? New Qs
hypotonia

Reflexes Normal or Sluggish Absent


increased

Seizures No seizures Seizures are Seizures are


and symptoms common frequently
usually resolve in seen and
<24 hours more resistant
to treat with
anticonvulsants

EEG Normal Abnormal Abnormal with


decreased
a. Erythema toxicum neonatorum background
b. Exanthem subitum activity
c. Erythema infectiosum Apgar score 5 to 7 3 to 4 1 to 2
d. Kissing disease.
Option a: Stage 1 will have a hypertonic and irritable child in which
 [Ref: Nelson, 21st ed., p. 13324]
seizures are usually absent.
Explanation: Erythema toxicum neonatorum is an Erythematous Option b: Stage 3 will have a flaccid child along with the absent reflexes.
macule with a central tiny papule, seen anywhere—except the palms Option c: Stage 4 is not classed under Sarnat staging
and soles. The lesions are packed with eosinophils, and there may be 442. A mother brings her 1-day-old neonate who was born at home.
accompanying eosinophilia in the blood count. The cause is unknown, On asking history the mother
and no treatment is required as the rash disappears after 1–2 weeks. informs that the newborn had a
441. A 25-year-old mother Mala delivered her child in a PHC, After delayed cry after birth. When she
delivery, neonate had delayed cry after birth and developed features started feeding her, there were a
of hypoxic ischemic encephalopathy (HIE). The DMO referred the history of poor feeding along with
newborn to the higher center for evaluation. On examination, the few episode of seizures. A MRI was
neonate had hypotonia, exaggerated ankle reflex, recurrent focal advised and shows the following
seizures along with a miotic pupils. What is the most likely stage abnormality, what is the most likely
of HIE according to Sarnat staging system? New Qs diagnosis? New Qs

a. Stage 1 b. Stage 2 a. Periventricular leukomalacia


c. Stage 3 d. Stage 4 b. Germinal matrix hemorrhage
 [Ref: Nelson, 21st ed., p. 3953] c. Status marmoratus with basal
ganglia infarcts
Explanation: Based on the clinical findings of hypotonia, exaggerated d. Periventricular inflammation with ventriculitis
ankle reflex and recurrent focal seizures, which are typically seen in  [Ref: Nelson, 21st ed., p. 3938]
case of Stage 2 of HIE.
HIE—Refers to CNS dysfunction or encephalopathy associated with Explanation: This MRI is showing increased periventricular T2 signal
Perinatal asphyxia. on FLAIR image indicating Periventricular leukomalacia (PVL).
Potential to cause mortality and long-term sequel like disabilities and PVL has emerged as the principal form of brain injury in the premature
cerebral palsy. infant.
PEDIATRICS

1. Death of white matter (WM) in the brain’s Periventricular (PV) region


2. Caused by decrease in O2 or blood flow to PV WM
ANSWER KEY Clinical Correlates:
440. a 441. b 442. a y Developmental delay
y Seizures
y Spastic diplegia
Medicine
M edicine
— Dr Mohammed Shakeel Sillat

SYNOPSIS

GENERAL MEDICINE

APPROACH TO HYPONATREMIA
1174 SYNOPSIS

Lab Parameters SIADH* CSW** Central DI*** Nephrogenic DI Primary polydipsia


ADH levels ↑ N/↓ ↓ ­↑ ↓
Urine output ↓/N ↑ ↑ (>3L/Day) ↑ ↑
Serum sodium ↓ ↓ ↑ ↑ ↓
Serum osmolality ↓↓ ↓ ↑ ↑­ ↓
Urine sodium ↑ ↑↑ ↓ ↓
Urine osmolality ↑­ ↑­ ↓ (<200) ↓ (<200) ↑
Urine osmolality after No change No change ↑
water deprivation
Urine osmolality after ↑ No change ↑­
AVP
Hydration Euvolemia Dehydration Dehydrated Dehydrated Over hydration
Treatment Fluid restriction – TOC IV hypertonic saline Desmopressin Thiazide diuretics Fluid restriction
Loop diuretics, Fludrocortisone Amiloride
Demeclocycline

* Syndrome of Inappropriate ADH Release | ** Cerebral Salt Wasting Syndrome | *** Diabetes insipidus

APPROACH TO ACID-BASE DISORDERS


MEDICINE

* Normal anion gap metabolic acidosis or hyperchloremic metabolic acidosis.


**Mnemonic for high AG metabolic acidosis: DR MAPLES
MEDICINE
PSGN IgA nephropathy/Berger's disease Good Pasture's syndrome Alport syndrome Diabetic nephropathy 1196
• It is an immune-mediated • Respiratory/GI exposure to • Autoimmune disorder • MC hereditary nephritis. • MC systemic disorder
disease environmental agents → characterized by • Due to abnormality in type IV associated with nephrotic
• Seen 1–4 weeks after a skin or • ↑ mucosal IgA Synthesis → Formation formation of Anti-GBM collagen. syndrome
pharyngeal infection of circulating IgA complex → Gets Ab against both capillary • MC form of Alport syndrome is • Overall MCC of nephrotic
SYNOPSIS

• Due to group A β hemolytic entrapped in mesangium of lungs and glomerulus d/t mutation of the α5 chain of syndrome
streptococci (M type). • Seen in < 1 week of URTI (GBM) Type IV collagen • MC cause of chronic renal
• Usually affects children • MC cause of GN worldwide • Antibody formed is • α5-chain gene is located on ‘X’ failure

Facts
against noncollagenous chromosome
domain of α3 chain of • MC pattern of inheritance
Type IV collagen → X linked (classical Alport
syndrome)
• Can be inherited as X-linked, AR
or AD
• Development of hematuria • Synpharyngitic hematuria – • Pulmonary manifestations • Presents with a triad of → • Similar to nephrotic syndrome
1–4 weeks after an episode of Development of hematuria within are hemoptysis 1. Hereditary Nephritis: • Passage of foamy urine
URTI or skin infection (delayed 2–4 days of pharyngitis/URTI • Pulmonary hemorrhage  Recurrent gross hematuria • May present with
hematuria). • Recurrent Gross Hematuria → MC (diffuse alveolar  Proteinuria complications like diabetic
• Oliguria, edema, HTN clinical feature hemorrhage)  Progressive renal failure by retinopathy, CAD, neuropathy,
• Complete recovery in >95% • Persistent asymptomatic microscopic • Renal manifestations 30 years etc.
patients hematuria may be present are features of RPGN like 2. Sensorineural hearing loss:
• One attack confers lifelong • Usual age—2nd–3rd decade hematuria, proteinuria,  MC extrarenal manifestation
immunity rapidly progressive renal 3. Ocular abnormalities:

Clinical features
failure, etc.  Anterior lenticonus is
characteristic
 Cataract
 Keratoconus
• Transient • Normal C3 level • Normal complement level. • Kidney or skin biopsy • Microalbuminuria → 1st
hypocomplementemia • ASO titer → Normal • Circulating IgG anti, GBM • High frequency audiometry for clinically detectable sign/
• C3 levels ↓ and then return to Antibody SNHL Earliest clinical feature
normal • Dysmorphic RBC and RBC • Genetic analysis • Spot urine sample is preferred
• ASO titer↑↑ cast and is best
• Subnephrotic proteinuria • CXR → Diffuse B/L • Macroalbuminuria→ Indicates
(1–2 g/d) pulmonary infiltrates established disease

Investigations
• RBC and WBC casts in urine • ANCA may be +ve in upto
30% patient
• Crescents • Mesangioproliferative GN • Diffuse crescenteric GN • EM → Irregular thinning and • Diffuse glomerulosclerosis:
• Hypercellularity of mesangial • IF → Mesangial deposits of IgA • IF → Diffuse linear IgG splitting of GBM giving a basket • MC pattern
and endothelial cells (subclass IgA1) often with C3 and staining along BM weave appearance or split • Thickening of GBM
• Subendothelial deposits and Properidin basement membrane • Capsular hyaline drops or fibrin
subepithelial humps • IgG deposits may also be seen caps may be present
• EM → Electron dense deposits in • Nodular glomerulosclerosis

Microscopy
mesangium • Also known as Kimmelstiel
Wilson lesion
• Pathognomonic of DM.
• Early systemic antibiotic • Rx: ACEI for proteinuria • T/T → Plasmapheresis • Lenticonus + Hematuria is • Armani - Ebstein cells →
therapy for throat or skin considered pathognomonic for Tubular cells with glycogen
infection will not eliminate the classical Alport. deposit
risk of GN • Kidney size may increase in

Extra edge
• Recurrence → Rare • Recurrence → Common • Recurrence of disorder in renal initial stage of disease
• Prognosis – excellent transplant → rare
TEN into TEN 1205

Polycythemia Vera Myelofibrosis Essential Thrombocytosis


Lab features • ↑Hb% and RBC count • ↑ LAP score • ↑ platelet count (>600 × 109/L)
• ↑ HCV/Venous HCT >55% • PS → Teardrop cells/ • Hematocrit and RBC – Normal
• ESR ↓ ; EPO ↓ ; LAP score↑ Dacrocytes and • N/↑ LAP score
• Abnormal platelet function Pancytopenia • Abnormal bleeding time
• ↑ Vitamin B12 binding capacity • Hypercellular bone
• ↑ Uric acid marrow
• IOC – Red cell mass (Increased) • Dry tap on aspiration
• BM biopsy → reticular/
collagen on biopsy
(IOC)
Management • Venesection • Hydroxyurea • Splenectomy • Asymptomatic patient → No
• TOC for Erythromelalgia → • Anagrelide • JAK-2 inhibitors therapy
NSAIDs • Radioactive iodine P32 • Symptomatic patient → IFN and
Anagrelide

RHEUMATOLOGY

MANAGEMENT OF RHEUMATOID ARTHRITIS

MEDICINE
Medicine
Dr Mohammed Shakeel Sillat

GENERAL MEDICINE
[Total Questions 104]

ACID-BASE DISORDERS Disorder Prediction of Range of value


compensation pH HCO–3 PaCO2
1. Patient was being treated in ICU for sepsis. ABG showed
pH = 6.9, pO2 = 80 mm Hg, pCO2 = 55 mm Hg, HCO3 = 10 mEq/L. Chronic [HCO ] will ↓ 0.4 mmol/L

3
Repeating ABG after 2 hours shows pH = 7.1, pCO2 = 20 mm Hg, per mm Hg ↓ in PaCO2
pO2 = 100 mm Hg, HCO3 = 10 mEq/L. Which is the most plausible Respiratory Low High High
explanation for change seen in ABG report? (INI-CET NOV 2023) alkalosis
a. Excess air and less heparin in ABG sample
b. Excess air and more heparin in ABG sample Acute [HCO–3] will ↑ 0.1 mmol/L
c. Less air and more Heparin in ABG sample per mm Hg ↑ in PaCO2
d. Less air and less heparin in ABG sample Chronic [HCO–3] will ↑ 0.4 mmol/L
 [Ref: J Ped Nephrol 2019; 7(3)] per mm Hg ↑ in PaCO2

2. What is the diagnosis in a sick COPD patient with pH = 7.3, 3. Calculate the anion gap from the following values: Na+145 mEq/L,
pCO2 = 80 mm Hg, and HCO3 = 28 mEq/L? (INI-CET NOV 2023)
K+ 4 mEq/L, CI– 90 mEq/L, HCO3– 20 mEq/L. (INI-CET MAY 2023)
a. Respiratory acidosis due to hyperventilation and adequate
a. 35 b. 68
compensation
c. 25 d. 43
b. Respiratory acidosis due to hyperventilation and partial
compensation  [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
c. Respiratory alkalosis due to hyperventilation and adequate p. 360]
compensation
Explanation: Anion gap = [Na+]–([Cl–] + [HCO3–])
d. Respiratory alkalosis due to hyperventilation and partial
compensation 4. A patient presents with severe vomiting and diarrhea and has
 [Harrison’s Principles of Internal Medicine, 21st ed., orthostatic hypotension. What metabolic abnormalities would
p. 361] you expect in this patient? (INI-CET MAY 2023)
Explanation: In acute respiratory acidosis, there is 1 mEq/L increase in a. Hypokalemia b. Hypochloremia
c. Metabolic alkalosis d. Respiratory alkalosis
HCO3 per 10 mm Hg rise in PaCO2. In chronic respiratory acidosis (after
24 h), there is 4 mEq/L increase in HCO3 for every 10 mm Hg increase  [Harrison’s Principles of Internal Medicine, 21st ed.,
in PaCO2. In this COPD patient with chronic respiratory acidosis, PaCO2 p. 366]
increased by 40 mm Hg, hence, expected HCO3 would be approx 40
5. Which of the following can be used to determine the acid-base
mEq/L.
imbalance? (INI-CET MAY 2023)
Prediction of compensatory responses to simple acid-base 1. Arterial pH 2. Venous pH
disturbance and pattern of changes 3. Venous pO2 4. Venous pCO2
Disorder Prediction of Range of value Select the correct answer from the given code.
compensation pH HCO–3 PaCO2 a. 1 b. 1, 4
Metabolic PaCO2 = (1.5 × HCO ) + 8 + 2
– Low Low Low c. 1, 3, 4 d. 1, 2, 3, 4
3
acidosis  [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
Metabolic PaCO2 will ↑ 6 mm Hg per High High High p. 359]
alkalosis 10 mmol/L ↑ in [HCO–3]
ANSWER KEY
Respiratory High Low Low
1. b 2. b 3. a 4. d 5. a
alkalosis
Acute [HCO–3] will ↓ 0.2 mmol/L
per mm Hg ↓ in PaCO2
TEN into TEN 1211

17. Identify the regions marked A and B in the following image: 18. Metabolic acidosis with a normal anion gap is seen in a patient with:
 (INI-CET NOV 2020) a. Alcohol intoxication b. Small bowel fistula
c. Shock d. Aspirin ingestion
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 364]
19. Urinary anion gap is increased in:
a. Diarrhea b. Water intoxication
c. Ureterosigmoidostomy d. Renal tubular acidosis
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 364]
20. All of the following are causes of metabolic acidosis with normal
anion gap; except:
a. Proximal renal tubular acidosis
b. Salicylate poisoning
c. Diarrhea
d. Pancreatitis
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 361]
21. A 60-year-old man, case of COPD is admitted with labored
breathing at rest and marked use of accessory muscles. Arterial
blood gas analysis reveals the following values:
pH 7.33, PaCO2 64 mm Hg, PaO2 50 mm Hg, HCO3 34 mEq/L
What is the possible diagnosis?
a. Metabolic acidosis with respiratory alkalosis
b. Chronic respiratory acidosis with compensated metabolic alkalosis
a. Chronic respiratory acidosis and metabolic acidosis c. Acute respiratory acidosis with compensated metabolic alkalosis
b. Metabolic alkalosis and metabolic acidosis d. Respiratory and metabolic acidosis
c. Acute respiratory acidosis and chronic respiratory alkalosis
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
d. Acute respiratory acidosis and metabolic acidosis
p. 359]
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 359] 22. Best management option for respiratory alkalosis is:
a. Acetazolamide b. IPPV
Explanation: c. Normal saline d. Rebreathing from a paper bag
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 368]
23. A 70-year-old man with history of CHF presents with shortness of
breath and leg swelling. ABG shows pH 7.24, PCO2 60 mm Hg, PO2
52 mm Hg, HCO3 27 mEq/L. What is the primary acid-base disorder?
a. Respiratory alkalosis b. Metabolic alkalosis
c. Metabolic acidosis d. Respiratory acidosis
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 359]
24. Type B lactic acidosis occurs due to:
a. Cyanide poisoning b. Diabetes mellitus
c. CHF d. Severe anemia
 [Ref: Harrison’s Principles of Internal Medicine, 21st ed.,
p. 361]

Explanation: Type A lactic acidosis can result from inadequate tissue


perfusion, which may stem from circulatory insufficiency (such as shock
or cardiac failure), severe anemia, mitochondrial enzyme defects, or
exposure to inhibitors like carbon monoxide or cyanide.
MEDICINE

ANSWER KEY
17. a 18. b 19. d 20. b 21. b 22. d
23. d 24. b
S

Surgery
urgery
— Dr Rohan Khandelwal

SYNOPSIS

GENERAL SURGERY

DAY CARE SURGERY Energy Sources

Enhanced recovery after surgery (ERAS) protocol: Monopolar cautery Bipolar cautery

Preoperative Intraoperative Postoperative Current flow: • Current enters


• Current from machine to tip, surgeon uses through one
• Avoid mechanical • Minimally invasive • Opioids only for tip to cut or coagulate channel and exits
bowel preparation surgical approach breakthrough pain • Current leaves body through cautery pad from another
• Solids up to 6 hours • Local anesthetic • Regular diet within • Cautery pad should be placed over a well channel
prior to surgery or long acting 24 hours vascularized area and should have a wide • Circuit is getting
• Clear fluids local (liposomal • Discontinue IV area of contact locally completed
up to 2 hours bupivacaine) fluids within • If small cautery pad/improperly placed pad:
prior to surgery • Prophylaxis for 24 hours There can be burns at the site of attachment
(carbohydrate nausea and • Ambulate within • Cautery pad not placed → Incomplete
loading can be vomiting 24 hours circuit → Cautery will not work
done) (at least 2 classes
of medications) Can injure nerves and end arteries and nearby Can be used near
vital structures (current traveling throughout vital structures, end
the body) arteries
SURGICAL BLADES AND ENERGY SOURCES Avoid near nerves, end arteries (e.g., ear lobule, Surgeries used:
penis) and in patients with cardiac pacemakers. • Thyroid
y Number 11 (Pointed/tab blade): For incision and drainage. • Parotid
y Number 12 (Curved): For suture removal. • Penile
y Numbers 10, 15, 20, 21, 22, 23: For making incisions.
Can cut and coagulate Only coagulate
y Blades are passed in a kidney tray to prevent injury.
y Incision must be made from far to near.

Bard Parker handle Monopolar cautery Bipolar cautery


1366 SYNOPSIS

SURGICAL SAFETY CHECKLIST Sitting/Fowler’s position:


y Used for posterior cranial fossa
Sign in Time out Sign out surgeries.
y Advantage: Relatively bloodless
Before induction of Before skin incision Before patient leaves
anesthesia. operating room, at
field good exposure.
From ward to OT skin closure y Disadvantage: Air embolism if
table veins are nicked.
Written consent, Reconfirm the identity of Nurse: Gauze and
confirm the patient instrument count
identity of patient, Surgeon says: Name of Anesthetist: Actual
confirm site procedure, estimated blood loss
marking, inquire blood loss Surgeon: Specimen
about allergies Anesthetist says: Antibiotic labeling
prophylaxis given DRAINS, SUTURES AND KNOTS

Drains
OT POSITIONS
y Corrugated rubber drain: Open
Supine position: drain for abscesses. Rarely used.
y M/c position for abdominal and
breast surgeries.

y Romovac suction drain: Closed


Trendelenburg position:
drain with negative pressure.
y Used in pelvic surgeries.
Can be used after mastectomy,
y Foot end is raised, head end is low.
thyroidectomy, neck dissection.

Reverse Trendelenburg position:


y Used in laparoscopic
cholecystectomy.
y Head end is raised, foot end is low.

y Abdominal drain: Connected to


abdominal drainage bag.
Lithotomy position:
y Used in obstetric, gynecological
and urological procedures.
y Common peroneal nerve injured if
legs are not supported properly in
lithotomy position.

Lateral or kidney position:


Uses:
y Thoracotomy
y Pyelolithotomy
y Nephrolithotomy
y Nephrectomy y Underwater seal bag: Connected
Brachial plexus injury occurs if arms are to intercostal chest tubes.
hyperextended in lateral position.
SURGERY

Prone position:
y Used for spinal surgery and
pilonidal sinus surgery.
TEN into TEN 1419

M/c site: Face (above line joining angle of mouth to ear lobule).

Malignant Melanoma
Risk factors:
y UV radiation
y White population.
y Familial atypical mole melanoma syndrome.
Types:
y Superficial spreading:
 M/c type.
 Seen in young.
 Sun exposed areas.
 M/c melanoma in a pre-existing mole.
y Lentigo maligna: Rx:
 In situ melanoma. Wide local excision
 Elderly patient. If LN not enlarged → SLNB is done.
 Best prognosis. Most important prognostic factor: LN status.
y Acral:
Marjolin’s ulcer:
 M/c in dark skinned patients.
Long standing burns/venous ulcers → SCC.
 Seen in palm, sole.
y Nodular:
 Most aggressive.
 Worst prognosis.
 Rapid vertical phase of growth.
 Variant: Amelanotic melanoma.
y For detection of melanoma:
 A → Asymmetry
 B → Borders which are uneven
 C → Change in color
 D → Increase in diameter >6 mm
IHC markers:
y S–100.
y HMB 45.
y Melan A.
SURGERY
Surgery
Dr Rohan Khandelwal

GENERAL SURGERY
[Total Questions 136]

1. Open cardiac massage is what kind of wound?  4. Identify the surgical instrument shown in the image. 
 (INI-CET NOV 2023)  (INI-CET MAY 2023)
a. Clean b. Contaminated
c. Dirty d. Clean contaminated
 [Ref: Bailey & Love’s Short Practice of Surgery, 28th ed.,
p. 973]
2. Feeding is done through the method shown in image. Which of
the following is not a complication?  (INI-CET MAY 2023)

a. Mixter b. Adson’s
c. Kocher’s d. Rampley
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
 ch. 11, p. 123]

Explanation: The Mixter instrument is a long, narrow, curved


a. Aspiration b. Pneumothorax instrument with a blunt end that is used to dissect and retract soft tissues
c. Refeeding syndrome d. Osteoporosis during surgery. It is commonly used in thyroid and parathyroid surgery.
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
ch. 40, p. 437] 5. A 25-year-old male was brought to the casualty after road traffic
accident with pelvic fracture in hypovolemic shock. What is the
Explanation: Aspiration is a complication of enteral feeding where food earliest treatment for control of hemorrhage?
or fluids enter the lungs, causing pneumonia or lung abscess. It is not a a. Immediate internal fixation (INI-CET MAY 2023)
complication of the feeding method itself, but rather a complication of b. Multiple blood transfusions
the patient’s ability to swallow or clear their airway. c. Use bedsheets to compress the pelvis
d. Emergency external fixation
3. A 28-year-old female presenting with 36 weeks of gestation,
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
underwent a C-section for placenta accreta spectrum. During the
ch. 60, p. 655]
procedure, there was profuse bleeding and she was transfused
blood according to the massive blood transfusion protocol. Which Explanation: Emergency external fixation is the earliest treatment for
of the following is not seen after a massive blood transfusion? control of hemorrhage in a patient with a pelvic fracture in hypovolemic
 (INI-CET MAY 2023) shock. This is a temporary measure that is used to stabilize the pelvis and
a. Hypothermia b. Hypomagnesemia stop the bleeding.
c. Hypokalemia d. Hypocalcemia
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
ch. 35, p. 377] ANSWER KEY
Explanation: Hypokalemia is a common electrolyte abnormality 1. b 2. a 3. c 4. a 5. d
following massive blood transfusion. This is due to the release of
potassium from red blood cells during transfusion.
TEN into TEN 1531

782. A patient is undergoing a surgery during which the nurse passes 784. A patient presented with severe pain in his abdomen.
this over to the surgeon. What is this patient most likely being Imaging findings are shown here. What is the most likely
treated for? New Qs diagnosis? New Qs

a. Urolithiasis b. Male infertility a. Pyelonephritis b. Polycystic kidney


c. Male sexual dysfunction d. Lithotripsy c. Renal artery stenosis d. Ureteric stones
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,  [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
p. 680] p. 456]
Explanation: The picture shows the implantable inflatable penile Explanation: This picture shows an intravenous pyelogram of the
prosthesis used in erectile dysfunction (ED). This consists of fluid kidneys showing spider leg appearance. Polycystic kidneys have this
containing paired corporal cylinders, a scrotal pumping device and a specific appearance on IVP. The renal shadow is enlarged. The renal
fluid reservoir, which is typically positioned in the retropubic space or pelvis is compressed and elongated. The calyces are narrow and stretched
extraperitoneal lower abdominal quadrant. over the cysts (Spider leg/bell shaped).
783. A male patient presented with pain in his scrotal area after a 785. A 45-year-male patient presented with a left-sided scrotal
trauma. The clinical finding is shown here. What is this patient swelling which the patient noticed recently. On examination,
most likely suffering from? New Qs it is transilluminant. He is undergoing removal and during
the surgery, the following finding can be noted. What is the
diagnosis? New Qs

a. Primary hydrocele b. Secondary hydrocele


c. Epididymal cyst d. Spermatocele
a. Extraperitoneal bladder rupture  [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
b. Intraperitoneal bladder rupture p. 645]
c. Anterior urethral rupture Explanation: Left-sided scrotal swelling which transilluminates – can
d. Posterior urethral rupture be primary hydrocele and epididymal cyst. Intraoperative picture shows
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed., a cystic swelling behind the testis. Whereas hydrocele fluid collects
p. 532] between the two layers of tunica vaginalis and testis is not seen until we
open the sac.
Explanation: This picture shows hematoma in the perineum and
SURGERY

scrotum (butterfly hematoma).


Urethral injury occurs due to blow onto perineum. The common ANSWER KEY
causes being cycling accidents, loose manhole covers and gymnasium 782. c 783. c 784. b 785. c
accidents. Bulbar urethra is crushed onto the pubic bone associated with
bleeding and bruising.
TEN into TEN 1533

790. A patient is undergoing a surgery during which this photo is taken. 792. A male patient presented with pain in his penis. Clinical finding is
What is the most likely diagnosis based on this image shown shown here. Which of the following cannot be done in this patient
here? New Qs to manage his condition? New Qs

a. Just penile bandage for 2 days


a. Pyocele b. Chylocele b. Needle puncture and release edema fluid
c. Dorsal slit
c. Hydrocele d. Spermatocele
d. Manual reduction under LA
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
p. 642] p. 518]
Explanation: You can visualize the white chylous fluid on opening the Explanation: The condition is paraphimosis, which is an emergency
tunica vaginalis. Hence, it is chylocele. Pyocele where pus is present. as it can progress to glanular gangrene. Manual reduction and needle
Spermatocele will not give this amount of fluid. puncture tried initially, when nothing works, dorsal slit and release of
constriction band to be done under penile block.
791. An elderly male presented with a lesion in the prepuce. On
examination, it can be retracted and left side swelling is fixed on 793. A male patient presented to the OPD with pain in his scrotal
palpation. Which of the following is the best step to manage this area and a huge swelling as shown in the image below. His BMI
patient’s condition? New Qs is 18 kg/m2. Which of the following is not done to manage this
patient’s condition? New Qs

a. Should be managed in foot end elevated position in bed


b. Should be reduced before surgery
c. Pneumoinsufflation of the abdomen using laparoscope to be
a. Circumcision and radiotherapy to inguinal nodes
done before surgery
b. Glansectomy and ipsilateral inguinal block dissection d. Spirometry exercises to be advised two weeks before surgery
c. Partial penectomy and bilateral inguinal block dissection
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
d. Total penectomy and bilateral inguinal block dissection
p. 663]
 [Ref: Bailey & Love’s Short Practice of Surgery, 27th ed.,
p. 672] Explanation: The condition is huge inguinal hernia or scrotal abdomen
where most of the abdominal contents are in scrotum. These causes
Explanation: The condition is carcinoma of the prepuce without any deserve special attention as because are long way out of the abdominal
fixation, with fixed ipsilateral inguinal nodes which is N3. Ideal treatment cavity, sudden reduction inside abdominal cavity will cause respiratory
will be circumcision for primary. Fixed inguinal nodes should be started compromise and abdomen cannot accommodate. So, patient advised
on induction chemotherapy and radiotherapy is planned. Block dissection foot end elevation, pneumoinsufflation to increase the volume, and
to be done after this. spirometry to be advised.
SURGERY

ANSWER KEY
790. b 791. a 792. a 793. b
Many students remember complex surgical procedures better when they use
mnemonics, which simplify steps into easy-to-remember phrases.
O bstetrics and Gynecology

OBG
— Dr Sakshi Arora Hans

SYNOPSIS

OBSTETRICS

ANEUPLOIDY SCREENING
TEN into TEN 1579

Prophylaxis for infective endocarditis in heart disease patients


Heart disease where pregnancy is contraindicated
Not routinely given
(WHO category)
1. LV ejection fraction <30%. Indications
2. Severe mitral stenosis (Valve area <1.5 cm2) 1. To all HD patients undergoing cesarean delivery
3. Severe aortic stenosis (Valve area <1 cm2) 2. 
To HD patients undergoing vaginal delivery with following
4. NYHA grade 3/4 conditions:
5. Marfan syndrome with aortic root dilatation (≥4 cm)  Previous H/O infective endocarditis
6. Coarctation of aorta  Occurrence of valvulopathy after heart transplant
7. Pulmonary hypertension  Prosthetic heart valve
 Primary  In case of congenital heart disease if:
 Secondary: Eisenmenger syndrome ™ It is unrepaired
8. Peripartum cardiomyopathy with residual defects
™ Repaired within 6 months
9. Fontan surgery with residual defect
™ Repaired but residual defect present

DOC for Infective endocarditis: Ampicillin or Amoxicillin


Most Common in Heart Disease
In case of mitral stenosis:
M/C Heart disease in pregnancy y Ideally a female should conceive after surgical repair
Cause: Rheumatic heart disease y But if in pregnancy patient develops severe MS (area of valve
Lesion: Mitral stenosis <1.5 cm2)—advise b-blocker drugs to decrease heart rate and ↑LA
Second M/C heart disease in pregnancy filling time
Cause: Congenital heart disease y If medical management fails
Lesion: Atrial septal defect Next step: Balloon valvotomy done in T2.
M/C congenital valvular HD in pregnancy y Valve replacement is C/I in pregnancy
Mitral valve prolapse
M/C cyanotic congenital HD in pregnancy
Tetralogy of Fallot TERATOGENIC DRUGS
HD with maximum risk of maternal mortality
Eisenmenger syndrome Drugs Teratogenicity
M/C time of death in patients of Eisenmenger syndrome 1. Alcohol Goa’s: Growth Restriction
At the time of delivery or within 1 week of delivery Famous: Abnormal facial features
M/C maternal mortality is seen with which HD in pregnancy (smooth philtrum, thin vermilion border,
Mitral stenosis small epicanthal folds).
Beer: Abnormal brain development
microcephaly.
Management of HD in Labor Bar: Abnormal behavioral development
Preferred mode of delivery in heart disease patients—
1.  2. Phenytoin Fetal hydantoin syndrome
Vaginal delivery (i) Midfacial hypoplasia
2. Induction of labor—safe (ii) Upturned nose
(iii) Distal digital hypoplasia
3. Inducing agent
(Hypoplastic phalanges) ± cardiac
Cervix is ripe: Oxytocin defects
Cervix is not ripe: Foley catheter
3. ACE inhibitors/ • Renal hypoplasia/Renal agenesis
Preferred agent: Misoprostol

OBSTETRICS AND GYNECOLOGY


Angiotensin Receptor • Oligohydramnios in T2
Relative C/I: Dinoprostone Blocker
Delivery position—semi recumbent position with left lateral tilt
4. 
4. Lithium Ebstein anomaly
For pain relief—(mandatory pain relief ): Epidural analgesia
5. 
(Apical displacement of Tricuspid valve
6. IV fluid during labor—restrict to 1 mL/kg/hr → Tricuspid Regurgitation and Right
2nd stage of labor—should be cut short using forceps or
7.  atrial enlargement)
vacuum. Forceps preferred. In neonates it can lead to Floppy infant
8. 3rd stage of labor—AMTSL—done syndrome, diabetes insipidus and
 Methylergometrine is contraindicated hypoglycemia
 Oxytocin can be used 5. Isotretinoin Microtia/Anotia
 In case of MS give diuretics
6. Thalidomide Phocomelia (Proximal limb amputation)
Stillbirth
Heart Diseases where Cesarean Section is Mandatory
7. Warfarin DI SALA syndrome
Any heart disease where aorta is involved, e.g., • Chondrodysplasia
y Severe AS • Stippled Epiphysis
y Aortic aneurysm • Nasal hypoplasia
y Marfan syndrome with aortic root dilatation • CNS- Agenesis of corpus callosum
y If patient is on Warfarin at the time of delivery or within 2 weeks 8. Methotrexate Craniosynostosis: Cloverleaf skull
of delivery
Contd…
1582 SYNOPSIS

ECTOPIC PREGNANCY
OBSTETRICS AND GYNECOLOGY

Management of Ruptured Ectopic Investigations Done in Unruptured Ectopic


y Always surgical 1. TVS:
y No role of conservative management or medical management  Confirmed sign of Ectopic pregnancy: G: Sac + Y: Sac ± cardiac
y Route of surgery: activity seen in fallopian tube
If vitals stable: Laparoscopy/Laparotomy Suspicion of Ectopic if:
If unstable vitals: Laparotomy  Complex adnexal mass
y Surgery of choice:  Ring of fire on Doppler Seen
Unilateral SALPINGECTOMY  Empty uterus
on USG
y Surgeries never done: For ruptured ectopic  GSac without Yolk sac in tube.
1. Salpingo-oophorectomy 2. β-hCG:
2. Linear salpingostomy (Done for unruptured ectopic)  Critical value of hCG is that value of hCG above which in all
intrauterine pregnancies, G: Sac is visible inside uterus
TVS = 2000 I/U
TAS = 6500 I/U
1612 SYNOPSIS

Malpresentations seen in Congenital Malformation M/C complication: RPL

Specific Complaints in Unicornuate Uterus


y Unilateral dysmenorrhea
y Ectopic pregnancy
y Ectopic ovary
y U/L Renal anomalies

Relevant Embryology
1. Major part of female genital tract is derived from Müllerian duct.
2. Müllerian duct: Invagination of coelomic epithelium (at 6 weeks).
3. Each MD gives rise to that side FT, half of uterus, half of cervix
and upper half of vagina.
4. At 10 weeks: Right and left MD approach in midline and fuse
with each to form a septa.
Gynae Complications with Müllerian Malformation 5. Fusion begins in below upward direction.
y Infertility
y Outflow tract obstruction → hematometra 6. At 20 weeks: The septa dissolves (from below upward). A single
y Endometriosis uterine cavity is now formed.
y Dysmenorrhea 7. Last step: Fundus of uterus becomes dome shaped.

Obstetric Complications with Müllerian Malformation Vaginal development:


y Recurrent pregnancy loss (RR) Upper part: Müllerian duct
y Preterm labor Lower part: Sinovaginal bulb of urogenital sinus
y Malpresentation

Müllerian Malformations
CLASS HSG Image Comment
Class I: Müllerian agenesis – • Both MD Absent
• Ovary presents as it arises from
genital ridge

Class II: Unicornuate uterus • Single MD


• Single fallopian tube
On HSG
• Single FT
• Half of uterus
• Half of cervix and
• Half of upper vagina
• Banana shaped uterus
OBSTETRICS AND GYNECOLOGY

Unicornuate uterus

Class III: Uterus didelphys • Both MD are present but fail to fuse.
Hence 2 vagina seen
• It is the only condition where
2 vagina are present
• Hence on HSG 2 Leech Wilkinson
Cannula used

Uterus didelphys
Contd…
TEN into TEN 1613

CLASS HSG Image Comment

Class IV: Bicornuate Uterus (Grossly: Fundus of • MD Start fusing but fusion is
uterus is divided into incomplete.
2 parts) • There are two uterine horns and
single vagina.
• Cervix could be one or two
1. If there is single cervix: Unicollis
2. If 2 cervix: Bicollis

HSG of bicornuate uterus


• Angle between uterine horns: Obtuse
• Distance between horns ≥4 cm

Class V: Septate uterus (Grossly: Fundus of uterus • Both MD fused


is not divided) • Septa is formed
• But Septa fails to resolve
• There are 2 uterine horns and single
vagina
1. On HSG: It is difficult to
differentiate between septate
and bicornuate uterus
2. To differentiate between them
fundus of uterus should be
visible
In bicornuate: Fundus is divided
In septate: It is not divided

Note: Fundus of uterus fused in septate uterus. Septate uterus


• Angle between uterine horns: Acute
• Distance between horns <4 cm

Class VI: Arcuate uterus • Flat topped uterus or there is


slightly dipped fundus
• Best reproductive outcome

OBSTETRICS AND GYNECOLOGY

Arcuate uterus

Class VII: In utero exposure to Diethylstilbestrol • M/C malignancy a/w DES: Clear cell
(DES) cancer of cervix and vagina
• M/C uterine malformation a/w DES:
Hypoplastic uterus
• Most specific uterine malformation
a/w DES: T shaped uterus
• DES exposure does not lead to renal
anomalies in female fetuses.
OBG
Dr Sakshi Arora Hans

OBSTETRICS
[Total Questions 526]

ANATOMY AND PHYSIOLOGY OF Explanation: Pure gonadal dysgenesis results from a point mutation
REPRODUCTIVE ORGANS in SRY/SRY deletion or point mutations in another gene with testis-
determining effects (DAX-1, SF-1, CBX2). This leads to underdeveloped
1. Which of the following vessels will serve as an alternate source dysgenetic gonads that fail to produce androgens or AMH. This is
of blood supply to prevent uterine ischemia, in case the primary characterized by a normal prepubertal female phenotype and a normal
artery is ligated in the event of PPH?  (INI-CET NOV 2023) müllerian system due to absent AMH.
a. Ovarian artery b. Uterine artery Amongst the given options, a point mutation in the SRY gene is most
c. Arcuate artery d. Round ligament artery likely to result in complete gonadal dysgenesis but this answer remains
 [Ref: DC Dutta’s Textbook of Obstetrics, controversial as some other sources mention SRY deletion is more
10th ed., p. 389–392] commonly associated. The most common cause attributable to about
85% of cases is still idiopathic.
2. SRY region is located in:  (INI-CET MAY 2023)
a. Short arm of Y chromosome 4. Which of the following is incorrect regarding innervation of the
b. Short arm of X chromosome uterus? (INI-CET MAY 2022)
c. Long arm of Y chromosome a. Sensory level is from T10 to L1.
d. Long arm of X chromosome b. Uterine contractility is mediated by innervations from level
 [Ref: William’s Gynecology, 4th ed.; p. 408] T7-T8.
c. In the 1st stage of labor, pain is due to the fibers at level of
Explanation: Y-chromosome determines testes formation as testis- T10 to L1.
determining factor (TDF) is located on short arm of chromosome Y. TDF d. In early labor, pain is usually because of the uterine contraction.
is controlled by SRY gene (sex-determining region of Y chromosome).
The TDF differentiates Sertoli cells that start producing anti-  [Ref: DC Dutta’s Textbook of Obstetrics, 10th ed., p. 6]
Müllerian substance (AMS) or hormone. Anti-Müllerian substance
Explanation: The hormonal mechanisms mainly responsible for uterine
inhibits development of the Müllerian ducts.
Thus, absence of Y-chromosome (SRY gene) or TDF results in the contraction. The hormones which cause contractions are estrogen,
formation of ovary. prostaglandin and oxytocin, while relaxation caused by progesterone.
TDF also helps in differentiation of Leydig cells from mesoderm Uterine sensory supply is by ascending afferent fibers which is pass
of gonadal ridge. Leydig cells start secreting testosterone and through the inferior hypogastric plexus and enters the spinal cord
dihydrotestosterone 8 weeks onward next testosterone stimulates through T10-T12 and L1 roots.
growth of mesonephric duct that forms male genital duct system. Labor pain is due to stimulation of nocicepetors in the genital tract
Dihydrotestosterone helps in formation of penis, penile urethra, prostate caused by ischemia.
and scrotum. y First stage labor: Pain is mediated by T10 to L1 spinal segments. It is
caused by distension of the cervix and low uterine segment along with
3. In a 46XY female, on doing amniocentesis complete gonadal isometric uterine contraction.
dysgenesis was noted. Complete gonadal dysgenesis is caused by y Second stage labor: Pain is carried by T12 to L1 and S2 to S4 spinal
which of the following in the SRY gene? (INI-CET MAY 2023) segments. It is caused by tissue damage in the pelvis and perineum.
a. Point mutation b. Deletion of gene
c. Translation d. Inversion
 [Ref: William’s Gynecology, 4th ed., p. 413]

ANSWER KEY
1. a 2. a 3. a 4. b
Chunking information helps in making learning less overwhelming and
improves recall during exams.
TEN into TEN 1697

Explanation: The image of Partogram given is a. Deceleration in cardiotopography


NEW Partogram with cephalopelvic disproportion b. Acceleration in cardiotopography
c. Cannot be said
Old partogram New partogram
d. Normal cardiotopography
Latent Phase is induced Latent phase is Removed  [Ref: Williams Obstetrics, 25th ed., p. 335–339]
Square box = 1hour 2 Square box = 1 hour
412. Which of the following is not a contraindication for induction of
Acute phase starts from 3 cm Active phase starts from 4 cm labor?  (NEET PG 2019)
a. Pelvic tumor
408. A 35-year-old primigravida conceived after IVF cycles she attends b. Herpes infection
ANC check-up with 38 weeks POG. Her obstetric details reveal c. Heart disease
DCDA twins with 1st twin as a breech. On examination; BP d. History of lower transverse cesarean section in last two
>140/90 mm Hg on two occasions with proteinuria +1. How do pregnancies
you manage? (NEET PG 2020)
 [Ref: Williams Obstetrics, 25th ed., p. 503]
a. Watch out for BP and terminate when BP gets elevated.
b. Watch out for BP and induce on the EDD Explanation:
c. Immediate C section y Heart disease is currently not considered a contraindication for
d. Induction of labor induction, and vaginal delivery is preferred.
 [Ref: Williams Obstetrics, 25th ed., p. 458] y Induction: Implies stimulation of contractions before the spontaneous
onset of labor.
409. In atonic PPH, which of the following is done? (AIIMS NOV 2019)
Indications and Contraindications of Induction of labor (IOL)
1. Uterine massage is first step in the management
2. Suction of uterus Indications Contraindications
3. IV Methyl Ergometrine is given to all patients • ROM at term • Previous cesarean with a
4. B-Lynch suture is put if medical management fails classical uterine incision
a. 1, 2, 3 are correct • Non-reassuring fetal heart rate • Malpresentation (breech)
b. 1 and 3 are correct • Oligohydramnios • Placenta or vasa previa
c. 2 and 4 are correct • Prolonged pregnancy (post-term) • Estimated Fetal Weight
d. All four (1, 2, 3, and 4) are correct >4500 g
 [Ref: Williams Obstetrics, 25th ed., p. 793] • Rh alloimmunization • Severe fetal hydrocephalus
410. The following instrument is used in:  (AIIMS NOV 2019) • Placental insufficiency • Active genital herpes
• Gestational hypertension • Prior uterine surgery involv-
ing the myometrium
• Diabetes mellitus • Cervical cancer
• Intrauterine growth restriction

413. Which is true about normal partography?


a. Latent phase is till 5 cm cervical dilation
b. First stage is till the full cervical dilatation
c. Used mainly for maternal BP monitoring
d. Rate of dilatation in latent phase is 1 cm/h
 [Ref: Dutta’s Obstetrics, 9th ed., p. 491–493]
414. WHO modified partogram charting starts at cervical dilatation
of:
a. Cesarean section b. Vaginal hysterectomy

OBSTETRICS AND GYNECOLOGY


a. 2 cm b. 3 cm
c. Fothergill surgery d. Suction evacuation
c. 4 cm d. 5 cm
 [Ref: DC Dutta’s Textbook of Obstetrics, 9th ed., p. 616]
 [Ref: Dutta’s Obstetrics, 9th ed., p. 491; Holland and
411. What does the CTG graph show?  (AIIMS NOV 2019) Brews Obstetrics, 4th ed., p. 278]
415. Mrs S (G2 L1) presented to the hospital in labor pains. On
examination, she had 3 uterine contractions of 20 seconds in
10 minutes, cervical dilation was 6 cm and HR 145 bpm. What is
the stage of labor?
a. Stage I b. Stage II
c. Stage III d. Stage IV
 [Ref: Dutta’s Obstetrics, 9th/e, p. 113–115; Holland Brew’s
Obstetrics, 4th ed., p. 270–271; Williams Obstetrics, 24th ed., p. 412–417]

ANSWER KEY
408. c 409. c 410. a 411. a 412. c 413. b
414. c 415. a
TEN into TEN 1709

520. Hess’s formula is used in pregnancy to: Explanation:


a. Estimate fetal age
b. Identify fetal blood group
c. Identify fetal congenital malformations
d. Identify fetal sex
 [Ref: Dutta’s Obstetrics, 9th ed., p. 37; Forensic Medicine
& Toxicology, K.S.N. Reddy 33rd ed., p. 84]

Explanation: Hess’s rule:


y Used in pregnancy to estimate fetal age from the fetal length.
y States that the square of the number of calendar months of gestation
gives the length of the fetus in centimeters up to 5th month.
y The length of the fetus is determined by:
 Crown-rump length (from the vertex to the coccyx) in earlier
weeks
 Crown-heel length (from the vertex to the heel) from the end of
20th week onward Jolls retractor Czerny retractor
y After 5th month, however, the number of months should be multiplied
by 5, which gives the length in centimeters.
y Thus, the fetal age can be estimated from the fetal length as follows:
 Up to 5th month or 20th week— by square root of the crown-
rump length
 After 5th month— by dividing the crown-heel length by 5
521. According to the Registrar General of India, the most common
cause of IMR in India is:
a. Prematurity
b. Diarrhea
c. Malnutrition
d. Acute respiratory infection
 [Ref: Park’s Textbook of Preventive & Social Medicine,
23rd ed., p.569]
522. Which obstetric instrument has been shown in the photograph? Morris retractor Deaver’s retractor
523. During a suction dilation and curettage (D & C), the surgeons note
a midline perforation. If the uterus is not completely evacuated,
all of the following options may be indicated; except: New Qs

a. Continue with the same procedure


b. Exploratory laparotomy
c. Perform ultrasound
d. Exploratory laparoscopy
 [Ref: Dutta’s Obstetrics, 10th ed., p. 523–525]
524. A patient at 17 weeks gestation is diagnosed as having an intrauterine
fetal demise. She returns to your hospital 5 weeks later and her

OBSTETRICS AND GYNECOLOGY


vital signs are: blood pressure 110/72 mm Hg, pulse 93 beats/min,
temperature 36.38°C, respiratory rate 16 breaths/min. She has not
had a miscarriage, although she has had some occasional spotting.
Her cervix is closed on examination. This patient is at increased risk
for which of the following?
a. Septic abortion New Qs

b. Recurrent abortion
c. Consumptive coagulopathy
d. Future infertility
e. Ectopic pregnancies
 [Ref: Dutta’s Obstetrics, 10th ed., p. 310–312]

a. Jolls retractor
ANSWER KEY
b. Czerny retractor
c. Morris retractor 520. a 521. a 522. c 523. a 524. c
d. Deaver retractor
 Ref: Internet

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