November  | 2015

Forensic Medicine SPM

67. True statement(s) regarding the power of chief judicial 74. Which of the following is/are true about vasectomy:
magistrate: a. May affects erection of penis after procedure
a. Can give imprisonment of <3 year only b. Additional contraceptive is generally needed for around 12
b. Can give imprisonment of any duration weeks
c. Can give imprisonment up to 5 year c. Highly effective method of family planning
d. Can give imprisonment up to 7 year d. Minor surgical procedure
e. Can impose unlimited fine e. Incidence of recanalization is around 10% after procedure
75. All are elements of primary health care except:
68. Which of the following feature is/are related to mandible of
a. Adequate supply of safe water
male in comparison to female:
b. Provision of free essential drugs only to poor
a. Ascending ramus- smaller breadth
c. Promotion of food supply & proper nutrition
b. Angle of ramus- More obtuse
d. Prevention & control of locally endemic disease
c. Larger condyle e. Education concerning health problems
d. Mental tubercles- larger & prominent 76. MMR (Measles, mumps, rubella) vaccine is an example of:
e. Symphyseal height more a. Live attenuated vaccine

/e
69. Which of the following statement is/are true about b. Conjugated vaccine
carbamate poisoning: c. Polysaccharide vaccine

,8
a. Cause pinpoint pupil d. Killed vaccine
b. Atropine is antidote e. Toxiod
c. Adrenergic action 77. All are steps of investigation of an epidemic except:

d. Spontaneously hydrolyses from the cholinesterase enzy-
matic site
e. CNS toxicity is more as compared to organophosphorus
70. All are included in rape except:
a



rha. Verify the diagnosis
b. Before starting investigation, inform the media
c. Formulation of hypotheses
d. Confirmation of existence of an epidemic
ig
a. Insertion of finger in urethra e. Plan & implement control measures
b. Inserting object in cervix 78. Which of the following is/are method of health communi-
nd

cation:
c. Kissing
a. Lecture b. Imitation
d. Oral sex
c. Group discussion d. Panel discussion
ha

e. Rubbing finger on vagina

e. Role play
71. Which of the following is true about rigor mortis in 79. All are true about lepromatous leprosy(LL) except:
comparison to cadaveric spasm: a. Multibacillary(MB)- Multi drug therapy(MDT) is given
iC

a. Mechanism of rigor mortis is same as cadaveric spasm for treatment

b. Death clutch is seen in cadaveric spasm b. On split stain-multiple bacilli
c. Generally occurs 2-3 hours after death c. Sensation present in lesions
PG

d. Involves only certain groups of voluntary muscles d. Multiple symmetrical skin lesion present
72. Post-mortem caloricity is/are seen in all except: e. Lepromin test positive
a. Strychnine poisoning 80. Which of the following is part of national health policy 2015
b. Septicaemic condition draft except:
c. Cholera a. Increase GDP share to health to 5%
d. Barbiturate poisoning b. Assure universal availability of free, comprehensive
e. Tetanus primary health care services, as an entitlement, for all
73. Treatment of carbolic acid poisoning includes: aspects of reproductive, maternal, child and adolescent
health
a. Repeated lavage should be done
c. Provision of right to health
b. Intubation may be required in case of respiratory compro-
d. Engage private doctors
mise
e. Enable universal access to free essential drugs & diagnostics
c. Emetics is very beneficial
in public health facilities
d. Saline containing sodium carbonate is given i.v MCQs

Answer Key

67. d, e. 68. c, d, e. 69. b, d. 70. c. 71. b, c. 72. d. 73. a, b, d.

74.
b, c, d. 75. b. 76. a. 77. b. 78. a, c, d, e. 79. e. 80. a.

483
 PGI Chandigarh Self-Assessment & Review: 2017–2013

Ophthalmology ENT
81. Which of the following vitamin deficiency can cause 88. Which is true about Tuning fork test in hearing loss:
centrocecal scotoma: a. Rinne test is negative in conductive deafness
a. Vit A b. Weber test- lateralized to the worst ear in sensorineural
b. Vit E deafness
c. Lateralization of sound in Weber test with a tunning fork of
c. B6
512 Hz implies a conductive loss of 15-20 dB in ipsilateral
d. B2
ear
e. B12 d. Negative Rinne test indicates a minimum air-bone gap of
82. True about electroretinogram: 15-20 dB
a. a wave- arises from rods and cones e. A Rinne negative for all the three tunning forks of 256,512
b. b wave - d/t activity of bipolar cells & 1024 Hz indicates air-bone gap of 30-45
c. b-wave response is subnormal in early cases of retinitis 89. Which of the following causes lower motor neuron(LMN)
pigmentosa type of facial nerve paralysis :
d. c wave - representing metabolic activity of pigment epithe- a. Bell palsy
lium b. Parotid tumor
c. Guillain-Barré syndrome

/e
e. Best disease shows abnormal ERG
d. Middle cerebral artery infarct
83. True about Ciliary body:
e. Multiple sclerosis
a. It forms aqueous humour

,8
90. True about tympanometry:
b. Anterior smooth part is called pars plana a. Flat in ossiccular discontinuity
c. Ciliary processes are finger-like projections from the pars b. As type in otosclerosis

plicata part
d. Ciliary muscles help in accommodation
84. Which of the following statement(s) is/are true about Jones
dye test:
a


91.
rh c. Dome shaped indicates fluid in middle ear
d. Ad type in ossiccular discontinuity
e. C type in eustachian tube obstruction
True about bilateral abductor paralysis:
ig
a. Done for assessment of epiphora a. Voice is good
b. Positive test-1: primary hypersecretion b. Stridor is present
nd

c. Cords lie in abducted position

c. Negative test-1: partial obstruction or failure of lacrimal
d. Urgent tracheostomy is needed
pump mechanism.
92. All are true about mandible fracture except:
ha

d. Positive test-2: failure of lacrimal pump mechanism a. Condylar neck is most common site
e. Negative test-2: partial obstruction b. Malocclusion of teeth may occur
85. True about Kayser-Fleischer ring: c. Anterior superior alveolar nerve is most commonly injured
iC

a. Deposition of copper d. Panorex radiographs are useful for diagnosis

b. Deposition of iron e. Malunion& non-union are complications
c. Found in Wilson disease 93. True about chronic suppurative otitis media (CSOM):
PG

d. Deposition under Descemet’s membrane of the cornea a. Foul smelling discharge in atticoantral variety
86. Ectopia entis is/are associated with: b. Facial nerve involvement in tubotympanic variety
a. Homocystinuria c. Atticoantral variety is associate with cholestetoma
d. May cause hearing loss
b. Alport syndrome
94. True about ranula:
c. Lowe syndrome a. Mucous retention cyst
d. Marfan syndrome b. Seen in floor of mouth
e. Sulphite oxidase deficiency c. Marsupialization for large cyst
87. True about congenital esotropia: d. Parotid is most common site of origin
a. Amblyopia may develops e. Arises from sublingual salivary gland
b. Angle of deviation is usually fixed & large 95. Not a premalignant lesion of oral cavity:
c. Surgery should be done after 2 year a. Leukoplakia b. Erythroplakia
d. Onset only after 1 year of age c. Lichen planus d. Apthus ulcer
e. May be associated with inferior oblique overaction e. Submucosal fibrosis
MCQs

Answer Key
81.
e. 82. a, b, c, d. 83. a, c, d. 84. a, b, c. 85. a, c, d. 86. a, d, e. 87. a, b, e.
88. a, c, d. 89. a, b, c. 90. b, c, d, e. 91. a, b, d. 92. c. 93. a, c, d. 94. a, b, c, e.

95. d.

484
 November  | 2015

Medicine 103. Which of the following feature favours diagnosis of chronic

renal failure rather than acute renal failure:
96. Hain test is/are used for: a. Anaemia
a. Detection of INH resistance only b. Renal osteodystrophy
b. Detection of rifampicin resistance only c. Raised creatinine level
c. Detection of both rifampicin & INH resistance
d. Peripheral neuropathy
d. Detection of resistance of all drugs of first line ATT
e. Small kidney
97. True about Pulmonary artery catheterization (Swan-Ganz
104. Which of the following is/are true about sarcoidosis:
catheter placement):
a. Measures right atrial pressure a. Show cutaneous anergy
b. Measures left ventricular filling pressure b. High CD4/CD8 ratio
c. Measure PCWP c. Schauman bodies is pathognomic of sarcoidosis
d. Inserted through left subclavian vein d. May be associated with uveitis
e. Measures central venous pressure 105. Which of the following cranial nerve is/are involved in Gag
98. Presentation of tabes dorsalis includes: reflex :
a. Lancinating pain in leg a. 9
b. Loss of proprioception b. 10

/e
c. Sensory defect c. 11
d. No involvement of bladder & bowel d. 12

,8
e. Sensory ataxia e. 7
99. True about Prinzmetal’s angina: 106. Which of the following is/are true about Duchene muscular
a. May present at rest dystrophy:




b. Occurs due atherosclerotic obstruction of coronary arteries
c. Smoking is a risk factor
d. Nitrates are used for treatment
e. CCBs are used for treatment
a
rh
b.

a. Mental impairment may present
↑Serum CK levels
c. Cardiomyopathy may be present
ig
d. Autosomal recessive disorder
100. Which of the following is/are true about Revised Jones
Criteria 2015 of AHA  for diagnosis of acute rheumatic fever e. Onset during puberty
nd

: 107. True about acute intermittent porphyria:

a. Polyarthritis in low-risk populations is a major criteria a. Occur due to deficiency of enzyme HMB-synthase
b. Polyarthralgia in moderate- and high-risk populations is a b. Uroporphyrin is present in urine
ha

minor criteria c. Abdominal pain is common symptom

c. Monoarthritis in moderate- and high-risk populations is a d. ↑ Porphobilinogen in the urine
major criteria e. Leukocytosis is often present
iC

d. Echocardiography with Doppler study should be per- 108. Child Pugh A criteria for clinical severity of cirrhosis in-
formed in all cases of confirmed and suspected ARF cludes:
e. Echocardiography/Doppler study should be performed  to a. Bilirubin < 2.0 mg/dL
PG

assess whether carditis is present in the  absence of b. Prothrombin time >70 (% of control)
auscultatory findings c. Serum albumin 2.0-3.0 g/dl
101. Feature(s) of increased ICP is/are: d. Presence of encephalopathy
a. Hypotension b. Decrease HR e. Absence of ascites
c. Increase HR d. Hypertension
109. All are true about Abdominal aneurysm except:
e. Decreased level of consciousness
a. Atherosclerosis is the commonest cause
102. All are true about Hepatitis E except:
b. Most commonly arises from above the level of renal artery
a. May be fatal in pregnant women
b. May cause acute liver failure c. For asymptomatic aneurysms, repair is indicated if the
c. Carrier state is common diameter is >5.5 cm
d. Majority progress to chronicity d. Endovascular placement of an aortic stent is use for repair
e. Feco-oral transmission e. Mostly asymptomatic

MCQs

Answer Key

96. c. 97. a, b, c, d. 98. a, b, c, e. 99. a, c, d, e. 100. a, c, d, e. 101. b, d, e. 102. c, d.

b, d, e.
103. 104. a, b, d. 105. a, b. 106. a, b, c. 107. a, b, c, d. 108. a, b, e. 109. b.

485
 PGI Chandigarh Self-Assessment & Review: 2017–2013

110. A patient diagnosed with cushing’s syndrome. Dexamatha- Surgery

sone suppression test showed decrease in cortisol levels and
corticotrophin-releasing hormone (CRH) administration 116. Full form of SCIWORA is:
causes increased cortisol [Link] option(s) for this a. Spinal cord injury with radiographic abnormality
patient is/are: b. Spinal cord injury with radiographic aberration
a. Adrenalectomy c. Spinal cord injury without radiographic aberration
b. Pituitary irradiation d. Spinal cord injury without radiographic abnormality
c. Adrenal gland removal  e. Spinal cord injury with vertebral fracture with radiographic
d. Stereotactic pituitary radiosurgery abnormality
e. Surgical removal of ectopic tissue producing ACTH in dif- 117. Which of the following is/are true about breast carcinoma
ferent organs in male except:
111. In which of the following vasculitis lung involvement does a. Often presented at advanced stage at the time of diagnosis
not occur: b. Associated with gynaecomastia
a. Eosoniphilic granulomatosis with vasculitis c. Staging is different than female
b. Polyarteritis nodosa (PAN) d. Tamoxifene is used in treatment
c. Microscopic polyangitis  e. Associated with excess endogenous or exogenous oestrogen
d. Granulomatosis with polyangitis 118. All are true about medullary thyroid carcinoma except:

/e
e. Bechet syndrome a. Involves the parafollicular cell
112. Drug causing scleroderma is/are: b. Radiosensitive 

,8
a. Bleomycin c. Amyloid stroma is present
b. Pentazocin d. Elevated level of calcitonin
c. Polyinyl chloride e. High level of carcinoembryonic antigen


d. Steroid
e. Tetracycline
113. Which of the following is/are true regarding cardiac arrest
management according to 2015 American Heart Association
a

c.
rh
119. True about Caroli’s disease:
a. Intrahepatic bile duct dilation
b. Jaundice may be seen
↑ Serum alkaline phosphatase
ig
(AHA) Guidelines for Cardiopulmonary Resuscitation d. Not associated with portal hypertension
(CPR) and Emergency Cardiovascular Care (ECC): e. Surgery is treatment of choice localized hepatic involve-
nd

a. Biphasic shock is given initially with 120-200 Joules ment

b. Monophasic shock is given with 360 Joules 120. True about esophageal varices:
c. IV cannula is secured for administration of drugs a. Left gastric vein is portal vessel involved
ha

d. Biphasic defibrillators are preferred over monophasic b. Occur at mid esophagus level
devices c. Occur at pharyngeal level
d. Epigastric vein is systemic vein involved
iC

e. After placing an advanced airway, ventilation rate of 18-20

breaths per minute is maintained e. Occur at lower end of esophagus
114. A patient of asthma was on inhaled short acting β-agonist. 121. Which of the following is/are feature of highly selective
But there was no significant relief. After that he added low vagotomy in comparison to truncal vagotomy with drainage:
PG

dose of inhaled steroid from last 5 day by MDI, but still a. Better tolerated b. Dumping is more common
not responding. What you will advise him for next line of c. Diarrhea is less d. High recurrence rate
treatment: e. Operative mortality rate very less
a. Continue inhaled short acting β-agonist 122. Which of the following is/are true regarding parathyroid
b. Add inhaled long acting β-agonist gland surgery in parathyroid adenoma/hyperplasia:
c. Increase dose of inhaled corticosteroid a. Superior parathyroid gland lies posterior to RLN
d. Start oral corticosteroid b. Gland can be differentiated from surrounding tissue due
e. Start parenteral corticosteroid to its colour
115. Which of the following clinical criteria belongs to HIV stage I : c. The presence of a normal parathyroid gland at operation
a. Asymptomatic patient indicates that the tumor removed is an adenoma rather
b. Persistent generalised lymphadenopathy than parathyroid hyperplasia
c. Unexplained chronic diarrhoea for > 1 mth d. Intraoperative PTH estimation is done to check status of
d. Unexplained persistent fever (> 37.5°C for > 1 mth) gland removal
MCQs e. Neutropenia e. 6% person have 5 parathyroid gland

Answer Key
110.
a, b, c, d. 111. b. 112. a, b, c. 113. a, b, c, d. 114. a, b, c. 115. a, b. 116. d.

117.
c. 118. b 119. a, b, c, e. 120. a, e. 121. a, c, d, e. 122. a, b, c, d.

486
 November  | 2015

65. Ans:  c. Lymphocyte... group of proteins called proteorhodopsins are widly distrib-
uted in aquatic bacteria. It allows the cells to harvest the
[Ref: Harrison 19th/1190-91; Ananthanarayan 9th/473-74; Jawetz
27th/470-74]
energy of the sun light for phototrophic growth.
•• In contrast to the photosynthesis of endosymbiontic
Cytomegalovirus (Human Herpes Virus Type 5) chloroplasts in plants and previously known groups of
•• It is cytomegalic (not lymphoproliferative, which occur in photosynthetic bacteria no electron transport is involved.
HHV4, 6 & 7) Therefore bacterio- and proteorhodopsin-mediated
•• Characterized by enlargement of infected cells phototrophic growth results in “proton transport
•• Congenital infection- Intrauterine infection leads to fetal phosphorylation, in contrast to the “electron transport
death or cytomegalic inclusion disease of newborn which phosphorylation” of the classical photosynthesis. However,
is often fatal both processes involve integral membrane proteins and
Cytomegalovirus (Human Herpesvirus Type 5) result in an electrochemical gradient across a membrane
–– Harrison 19th/1190-91 which powers the ATPsynthase.
•• Human CMV is one of several related species-specific “Bacteriorhodopsin (BR) is a relatively small membrane
viruses that cause similar diseases in various animals. All are protein. As all membrane proteins, it has been particularly
associated with the production of characteristic enlarged challenging to structural analysis, due to difficulties in the
cells—hence the name cytomegalovirus. process of purification. Membrane proteins, contrary to non-

/e
•• Cytomegalic cells in vivo (presumed to be infected epithelial membrane proteins, expose their non-polar (hydrophobic)
cells) are two to four times larger than surrounding cells and residues to the exterior. BR functions as a pump of protons

,8
often contain an 8- to 10-μm intranuclear inclusion that from the cytoplasm to the extracelullar space, in order to create
is eccentrically placed and is surrounded by a clear halo, a proton gradient. Afterwards, protons enter the cell again
producing an “owl’s eye” appearance. favourably, and the cell takes advantage of that by coupling to
•• In addition to inducing severe birth defects, CMV causes
a wide spectrum of disorders in older children and adults,
ranging from an asymptomatic subclinical infection
to a mononucleosis syndrome in healthy individuals to
a rh a reaction that synthesizes ATP. The energy required by BR is
provided by green light. At the end of the process, the outcome
is that the cell transformed energy from light into ATP, the
energetic currency of the cell” ([Link])
ig
disseminated disease in immunocompromised patients.
“Bacteriorhodopsin is a trans-membrane protein found
•• Primary infection with CMV in late childhood or adulthood
in the cellular membrane of Halobacterium salinarium,
nd

is often associated with a vigorous T lymphocyte response

which functions as a light-driven proton pump. With the
that may contribute to the development of a mononucleosis
syndrome similar to that which follows infection with recent determination of the structure of bR by electron cryo-
microscopy, simulation of the proton pump cycle has become
ha

Epstein-Barr virus. The hallmark of such infection is the

appearance of atypical lymphocytes in the peripheral feasible” ([Link]/)
blood; these cells are predominantly activated CD8+ T “Bacteriorhodopsin is a proton pump found in Archaea, it
iC

lymphocytes. takes light energy and coverts it into chemical energy i.e.
•• Polyclonal activation of B cells by CMV contributes to the ATP, that can be used by the cell for cellular functions” (www.
development of rheumatoid factors and other autoantibodies [Link])
PG

during mononucleosis.
66. Ans:  a. Present..., b. It acts as..., c. Generate...,
d. Same as rho....
Forensic Medicine
[Ref:[Link]/Research/newbr/]
67. Ans:  d. Can give imprisonment..., e. Can impose....
“Bacteriorhodopsin is a protein used by Archaea, most
notably by Halobacteria, a class of the Euryarchaeota. It [Ref: Reddy 32nd/6; Reddy 27th/6 [Link]]
acts as a proton pump; that is, it captures light energy and In new edition of Reddy (32nd),amount regarding fine imposed
uses it to move protons across the membrane out of the cell. by 1st & 2nd class magistrate is given wrong(!!!).
The resulting proton gradient is subsequently converted into But in old edition (27th), it was correctly given
chemical energy”
“Rhodopsin is a biological pigment found in the rods of the
Table (Reddy 32nd/6): Powers of magistrate
retina and is a G-protein-coupled receptor (GPCR). Rhodopsin
is extremely sensitive to light, and thus enables vision in low- Class of magistrate Imprisonment Fine
light conditions. When rhodopsin is exposed to light, it
immediately photobleaches. In humans, it is regenerated fully Chief judicial magistrate Up to seven years Unlimited
in about 45 minutes”
Bacteriorhodopsin I class judicial magistrate Up to three years 10,000 rupees
–– [Link]-duesseldorf Answers
II class judicial magistrate Up to one year 5000 rupees &
•• It is a light-driven proton pump that was first found in halo- Explanations
philic archaea. Recently it was shown that a homologous

531
 PGI Chandigarh Self-Assessment & Review: 2017–2013

Table (Reddy 27th/6): Powers of magistrate •• It differs toxicologically from organophosphate:

They will spontaneously hydrolyse from the cholinester-

Class of magistrate Imprisonment Fine ase enzymatic site within 24 to 48 hours, whereas or-
Chief judicial magistrate Up to seven years Unlimited ganophosphates will not;
 They do not effectively penetrate into the CNS, & as such
I class judicial magistrate Up to three years 5000 rupees
CNS toxicity is limited
II class judicial magistrate Up to one year 1000 rupees •• All other clinical manifestations are similar to organopho-
dpahtes
Section 29 in the Code of Criminal Procedure, 1973 •• Treatment: Atropine is the specific antidote. Pralidoxime
–– [Link], Also confirmed by lawyers may diminish the severity of symptoms & help prevent some
Sentences which Magistrates may pass morbidity. It improves respiratory functions & patients well
•• The Court of a Chief Judicial Magistrate may pass any being
sentence authorised by law except a sentence of death or Organophosphorus Poisoning
of imprisonment for life or of imprisonment for a term –– Reddy 32nd/495-97; KDT 7th/111
exceeding seven years. •• Pupil: Miosis, occasionally unequal or dilated
•• The Court of a Magistrate of the first class may pass a •• Pralidoxime & atropine work synergistically & should be
sentence of imprisonment for a term not exceeding three

/e
used together
years, or of fine not exceeding five thousand rupees, or of •• All case of Anti-ChE poisoning must be must be promptly given
both. atropine 2 mg i.v repeated every 10 min till dryness of mouth

,8
•• The Court of a Magistrate of the second class may pass or other signs of atropinisation appear. Continued treatment
a sentence of imprisonment for a term not exceeding one with maintenance doses may be required for 1-2 weeks
year, or of fine not exceeding one thousand rupees, or of •• The use of oximes in organophosphate poisoning is
both.
•• The Court of a Chief Metropolitan Magistrate shall have
the powers of the Court of a Chief Judicial Magistrate and
that of a Metropolitan Magistrate, the powers of the Court
a rh secondary to that of atropine. Moreover, the clinical benefit
of oximes is highly variables
ig
70. Ans:  c. Kissing
of a Magistrate of the first class.
[Ref: Reddy 32nd/ 392; Parikh 7th/389-90]
nd

68. Ans:  c. Larger..., d. Mental tubercles..., e. Symphyseal.... Rape: The Criminal Law (Amendment) Bill, 2013 (S.375,
[Ref: Reddy 32nd/60; Parikh 7th/ 79] I.P.C)
ha

Symphyseal height is more in males (Parikh 7th/79) A person is said to commit sexual assault if that person (Reddy
32nd/ 392)
Table ( Reddy 32nd/60): Trait diagnostic of sex from skeleton (Man- •• Penetrates his penis, to any extent, into the vagina, mouth,
iC

dible) urethra or anus of another person or makes the person to

do so with him or any other person
Trait Male Female •• Inserts, to any extent, any object or a part of the body,
PG

General size Larger & thicker Smaller & thinner not being the penis, into the vagina, the urethra or anus
Chin Square(U-shaped) Rounded of another person or makes the person to do so with him or
any other person
Body height At symphysis greater At symphysis smaller •• Manipulates any part of the body of another person so as
Ascending ramus Greater breadth Smaller breadth to cause penetration into the vagina, urethra, anus or any
Angle of body & Less obtuse(under More obtuse & not part of body of such person to do so with him or any other
ramus (Gonion) 1250); Prominent & prominent person
everted •• Applies his mouth to the penis, vagina, anus, urethra, of
another person or makes such person to do so with him or
Condyles Larger Smaller
any other person
Mental tubercles Large & prominent Insignificant •• Touches the vagina, penis, anus or breast of the person or
makes the person touch the vagina, penis, anus or breast
69. Ans:  b. Atropine.., d. Spontaneously... of that person or any other person, except where such
[Ref: Reddy 32nd/495-98; Parikh 7th/625-28; G & G 11th/210;KDT penetration or touching is carried out for proper hygienic
7th/111 ; Katzung 13th/979-80 ; Pharmacology by Satoskar 24th/297 ] or medical purposes under the circumstances falling under
any of the following seven descriptions
“Opiate overdose, pontine hemorrhage & organophosphate
 Against her will.
causes pin-point pupil”- [Link]
 Without her consent.
Carbamates (Derivative of carbonic acid)  With her consent, when her consent has been obtained by
Answers
& •• They are anticholinergic putting her or any person in whom she is interested, in fear
Explanations
•• Symptoms begin in 15 minutes to 2 hr of death or of hurt.

532
 November  | 2015

 With her consent, when the man knows that he is not her Feature Cadaveric Spasm Rigor mortis
husband and that her consent is given because she believes
that he is another man to whom she is or believes herself to Medicolegal Indicates time since Indicates
Importance death circumstances & mode
be lawfully married.
of deathQ e.g. suicide,
 With her consent when, at the time of giving such consent, homicide or accident
by reason of unsoundness of mind or intoxication or the
administration by him personally or through another of Conditions Simulating Rigor Mortis
any stupefying or unwholesome Substance, she is unable to 1. Cold stiffening
understand the nature and consequences of that to which 2. Heat stiffening or coagulation (Pugilistic attitude)
she gives consent. 3. Cadaveric spasm or Instantaneous Rigor
 With or without her consent, when she is under eighteen 4. Putrefaction (only written in Parikh)
years of age. Table: Rigor Mortis
 When she is unable to communicate consent.
According to Reddy According to Parikh
71. Ans:  b. Death clutch is seen..., c. Generally occurs....
• Time of onset: • In India rigor mortis commences
[Ref: Reddy 32nd/153-55; Parikh 7th/ 147-50; Modi 22nd/231] ƒƒ In India (tropical in 2-3 hours, takes about 12
countries) it starts 1-2 develop form had to foot,

/e
“Cadaveric spasm is also known as death clutch”-Textbook of
Forensic Medicine by NG Rao 1st/127 hours after death & persists for another 12 hours
takes further 1-2 hours & takes about 12 hours to pass

,8
Table:  Difference Between Rigor mortis & Cadaveric spasm to develop off. So if rigor mortis has not set
ƒƒ In temperate countries, in the time since death would be
Feature Cadaveric Spasm Rigor mortis it begins in 3-6 hours & within 2 hours & if it has affected
Definition This is continuation
after death, of the
state of contraction in
which muscles were at
This is d/t changes
in muscles after
molecular death
of their cells and is
a rh
•
takes further 2-3 hours
to develop
Duration:
ƒƒ In tropical countries
•
the whole body, the time since
death would be 12-24 hours.
It does not starts in all muscles
simultaneously (Nysten’s rule)
ig
the instant of death. preceded by general (India) it lasts 18-36 • Order of appearance &
The stage of primary relaxation of the hours in summer & 24- disappearance
nd

relaxation is absent. The muscles. A 2-3 hour 48 hours in winter ƒƒ Heart (left chamber in 1 hour)
stiffening is therefore lapse is therefore ƒƒ In temperate countries it → EyelidsQ (3-4 hrs) → Face
instantaneous at the necessary before lasts for 2-3 days muscles → Neck & trunk →
ha

time of death stiffening occurs. Upper extremities → legs →

Mechanism Not known Known Small muscle of finger & toes
(last to be affected, 11 -12
iC

Predisposing Sudden death None

hours)
factors
Emotional tension ƒƒ It passes off in same order of
(excitement, fear, appearance
PG

exhaustion) ƒƒ It usually lasts for 18-36

Physical activity at hours in summer & 24-28

the time of death hours in winter.

Preceded By Primary relaxation is Stage of primary

absent relaxation 72. Ans:  d. Barbiturate....
Time of onset Instantaneous 2-3 hours after death [Ref: Reddy 33rd/155, 32rd/149; Parikh 7th/143,6th/ 3.8-3.9]
Muscles Certain groups of All muscles, both Post- Mortem Caloricity
Involved voluntary muscles voluntary & involuntary
–– Reddy 33rd/155
Muscles Is quite marked and Is less marked & •• In this condition, the temperature of the body remains raised
stiffening considerable force is only moderate force for the first two hours or so after death
required to break it required to break it •• This occur
Molecular Does not occur Occurs  When the regulation of heat production has been severely
Death disturbed before death, as in sunstroke & in some nervous
Electrical Muscle respond Does not respond disorder
stimuli  When there has been a great increase in heat production
in the muscle due to convulsions, as in tetanus & strychnine
Produed Can not be produced Cold stiffening (<4°C)
by any method after & heat coagulation poisoning etc
Answers
death. It is impossible to (>70°C) simulate rigor  When there has been excessive bacterial activity, as in &
simulate it mortis septicaemic condition, cholera & other fevers Explanations

533
 PGI Chandigarh Self-Assessment & Review: 2017–2013

Post- Mortem Caloricity: Seen in Vasectomy

–– Parikh 6th/ 3.8-3.9 –– Park 23rd/509; Suryakantha 4th/686
 Pontine haemorrhage & sunstroke •• It is a permanent sterilization operation done in the male
 Tetanus & strychnine poisoning where a segment of vas deferens of both the sides are
 Acute viral or viral infections such as lobar pneumonia, resected & the cut ends are ligated
typhoid fever, encephalitis & encephalomyelitis •• It is a simple, cheap, safe, very effective, permanent & quick
surgical method of family planning
Post-Mortem Caloricity •• Failure rate is generally low, 0.15 pregnancies per 100
–– ourforensicmedicine. [Link]/2010/02/[Link] persons in the first year after the procedure
•• Septicaemia: Infectious diseases, Bacteremia, Tetanus, Ra- •• Additional contraceptive protection is needed for about
bies, yellow fever 2-3 months or at least 20-30 ejaculation(whichever comes
•• Asphyxial Conditions first) following operations, i.e. till the semen becomes free
•• Severe convulsions: Tetanus & Strychnine of sperm
•• Hyperpyrexia at death: Heat Stroke (sun stroke) & Pontine •• It is not castration, it does not affect the testes & it does
Haemorrhage not affect sexual ability. Some men may complain of
•• High Atmospheric Temperature diminution of sexual vigour, impotence, headache, fatigue
•• Peritonitis, Meningitis, Nephritis etc. Such adverse psychological effects are seen in men who

/e
•• Alcohol poisoning have undergone vasectomy under emotional pressure
“Factor affecting cooling of body (Algor mortis): Build of •• Autoimmune response: Normally, 2% of fertile men have

,8
cadaver: Children & old people cool more rapidly than adult” circulating antibodies against their own sperm. In men who
(Reddy 33rd/155)
have had vasectomies, the Fig.: can be as high as 54%. There
is no reason to believe that such antibodies are harmful to
73. Ans:  a. Repeated..., b. Intubation..., d. Saline containing...
[Ref: Reddy 32nd/507; Parikh 7th/535-37]
a rh ••
••
physical health
The incidence of recanalization is 0-6% after procedure
In no-scalpel vasectomy(NSV): In this instead of incision,
ig
Carbolic Acid small puncture is made & require no suturing of punctured
site, just a small bandage is sufficient
–– Reddy 32nd/507
nd

•• An emetic often fails due to the anaesthetic effect 75. Ans:  b. Provision of free....
•• Lavage: The stomach should be washed repeatedly,
carefully with plenty of lukewarm water containing activated [Ref: Park 23rd/ 891; Community Medicine with recent Advances by
ha

Suryakantha 4th/816]
charcoal, olive oil, caster oil etc. Washing continued until
the washings are clear & odourless Elements of primary health care: 8 Essential component
•• When lavage is completed, 30 9ram of magnesium sulphate oulined in Alma- (Ata declaration (1978) Park 23rd/ 891)
iC

or a quantity of medicinal liquid paraffin should left in the

stomach
•• Demulcent
PG

•• Saline containing sodium carbonate is given i.v to combat

circulatory depression, to dilute carboilic acid content of
blood & to encourage excretion by producing diuresis
•• Haemodialysis, if there is renal failure
•• Methylene blue, i.v, if there is severe methaemoglobinaemia
“Carbolic acid management: Evaluate and support airway,
breathing, and circulation. Children may be more vulnerable
to corrosive agents than adults because of the relatively smaller
diameter of their airways. In cases of respiratory compromise
secure airway and respiration via endotracheal intubation. If
not possible, surgically create an airway” ([Link])

SPM Fig.: (Suryakantha 4th/817): Principles & component of primary health

care
74. Ans:  b. Additional contrace..., c. Highly effective..., 1. Education concerning prevailing health problems &the
d. Incidence of.... methods of preventing & controlling them
Answers
& [Ref: Park 23rd/509;Cummunity Medicine with recent Advances by 2. Promotion of food supply & proper nutrition
Explanations Suryakantha 4th/686; Dutta Obs 8th/ 631-32] 3. An adequate supply of safe water & basic sanitation

534
 November  | 2015

4. Maternal & child health care including family planning accessible to individuals & acceptable to them, through their full
5. Immunization against major infectious diseases participation & at a cost the community & country can afford”
6. Prevention & control of locally endemic disease (Park 23rd/ 891)
7. Appropriate treatment of common diseases & injuries
8. Provision of essential drug 76. Ans:  a. Live attenuated...
“Definition of primary health care (Alma-Ata declaration1978): [Ref: Park 23rd/103; [Link] 8th/195-96; Community Medicine with
Primary health care is essential health care made universally recent Advances by Suryakantha 3rd/320]

Table (Park 23rd/ 103): Vaccine currently in Use

Live attenuated Killed whole organism Toxoid/ Protein Polysaccharide Glycoconjugate Recombinant
BCG, Yellow fever,OPV, Typhoid, Cholera, Plague, Diphtheria, Tetanus, Pneumococcus, Hib, Pneumococ- HBV, Lyme
Measles, Mumps, Rubella, Pertussis, Influenza, Acellular pertussis, Meningococcus, cus, MenACWY disease, Cholera
Typhoid, Varicella, Typhus, IPV, Rabies, JE,Tick Anthrax, Influenza Hib, Typhoid(Vi) (Meningococcus) Toxin B, HPV
Rotavirus, Cholera, borne encephailitis, HAV subunit
Cold-adopted influenza,
Rotavirus reassortants,

/e
Zoster

,8
77. Ans:  b. Before starting.... 78. Ans:  a. Lectu... c. Group..., d. Panel..., e. Role play...
[Ref: Park 23rd/131-33; Community Medicine by Piyush Gupta 1st/598- [Ref: Park 23rd/863-65; Cummunity Medicine with recent Advances by
603]

Investigation of an Epidemic
–– Steps Park 23rd/ 131-33
a rh
Suryakantha 4th/763;Community Medicine by Piyush Gupta 1st/756-65 ]
ig
•• Verification of diagnosis
•• Confirmation of existence of an epidemic
nd

•• Defining the population at-risk

•• Rapid search for all cases & their characteristic
•• Data analysis
ha

•• Formulation of hypotheses
•• Testing of hypotheses
•• Evaluation of ecological factors
iC

•• Further investigation of population at risk

•• Writing the report

Table  (Piyush Gupta 1st/598): Ten steps of a field investigation of

PG

Fig.: (Park 23rd/863): Methods in Health communication

epidemic
79. Ans:  e. Lepromin test....
1. Establish the existence of the outbreak. [Ref:Neena Khanna 5th/ 272-83; Roxburg 17th/;Park 23rd/314-29 ]
2. Confirm the diagnosis.
3. Create a case definition and determine the number of cases.
Slit smear: All patients who are AFB positive should be given
4. Describe the case according to time (onset), place and person multibacillary treatment, irrespective of the clinical presenta-
(age, sex, etc.) tion- Neena Khanna 5th/ 281,283
5. Formulate a hypothesis to explain the exposure and mode of “Skin lesion in Lepromatous leprosy(LL): Normoaesthetic/
transmission. minimally hypoaesthetic”- Neena Khanna 5th/ 276
6. Test the hypothesis by appropriate study (case control or Multi Drug Therapy (MDT) Blister Packs are Available in
cohort).
4 Colours
7. Compare the hypothesis with established facts and plan a more
systematic study. –– Neena Khanna 5th/ 284
8. Plan and implement control measures. 1. Adult multibacillary(MB) pack: Pink-red colour
9. Evaluate the effectiveness of control measures (establish a 2. Child multibacillary(MB) pack: Yellow colour
surveillance system). 3. Adult paucibacillary(PB) pack: Green colour
10. Prepare a written report 4. Child paucibacillary(PB) pack: Blue colour

Answers
&
Explanations

535
 PGI Chandigarh Self-Assessment & Review: 2017–2013

Table (Neena Khanna 5th/ 283): Profile of different types of leprosy

TT BT BB BL LL
Skin lesions
Number Single/few Few Several Numerous Innumerable
Size Variable May be large Variable Small Small
Sensations Anesthetic Hypoesthetic Hypoesthetic Hypoesthetic Normoesthetic
Symmetry Asymmetrical Asymmetrical Bilateral, but Tendency to symmetry Symmetrical
Asymmetrical
Morphology Macule/plaque; well- Plaques; well-de- Plaques; with sloping Macules/papules; Macules/papules;
defined fined with satellite edge (inverted saucer nodules/plaques, nodules/plaques, ill-
lesions appearance) ill-defined defined
Nerves
Number/symmetry Single trunk Few nerves, Several nerves, Several nerves, Several nerves,
asymmetrical asymmetrical almost symmetrical symmetrical

/e
involvement involvement involvement involvement
Character of nerve Early involvement. Thickened, with Thickened Glove and stocking Late involvement.

,8
involvement Related to lesion, anaesthesia in anaesthesia Glove and stocking
may be nodular distribution of nerve anaesthesia
Reactions Stable Type I Type I Type I/Type II Type II
Lepromin
Histology
Granuloma
+

Well-defined
+/–

Epithelioid cell
a –
rh
III-defined
–

III-defined
–

III-defined (loose),
ig
(compact), epithelioid granuloma macrophage macrophage foamy macrophage
cell granuloma granuloma granuloma with many granuloma
nd

lymphocytes
Gernz zone – + ++ ++ ++
ha

AFB – – +/– + ++
iC

80. Ans:  a. Increase GDP... National Health Policy 2015 Draft: Objectives
1. Improve population health status through concerted policy
[Ref: [Link] [Link].
in/[Link]?lid=3014] action in all sectors and expand preventive, promotive,
PG

curative, palliative and rehabilitative services provided by

“The Union Ministry of Health and Family Welfare has suggested the public health sector.
making health a fundamental right, similar to education. This 2. Achieve a significant reduction in out of pocket expenditure
key proposal in the draft National Health Policy, 2015, suggests due to health care costs and reduction in proportion of
making denial of health an offence”-the hindu paper households experiencing catastrophic health expenditures
“The National Health Policy accepts and endorses the and consequent impoverishment.
understanding that a full achievement of the goals and 3. Assure universal availability of free, comprehensive
principles as defined would require an increased public health primary health care services, as an entitlement, for all
expenditure to 4 to 5% of the GDP. However, given that the aspects of reproductive, maternal, child and adolescent
NHP, 2002 target of 2% was not met, and taking into account health and for the most prevalent communicable and non-
the financial capacity of the country to provide this amount and communicable diseases in the population.
the institutional capacity to utilize the increased funding in an 4. Enable universal access to free essential drugs, diagnostics,
effective manner, this policy proposes a potentially achievable emergency ambulance services, and emergency medical
target of raising public health expenditure to 2.5 % of the and surgical care services in public health facilities, so as to
GDP. It also notes that 40% of this would need to come from enhance the financial protection role of public facilities for
Central expenditures. At current prices, a target of 2.5% of GDP all sections of the population.
translates to Rs. 3800 per capita, representing an almost four 5. Ensure improved access and affordability of secondary
fold increase in five years. Thus a longer time frame may be and tertiary care services through a combination of public
Answers
appropriate to even reach this modest target”-[Link]. hospitals and strategic purchasing of services from the
& in private health sector.
Explanations

536
 November  | 2015

Influence the growth of the private health care industry

6.   Accountability: Financial and performance accountabil-
and medical technologies to ensure alignment with public ity, transparency in decision making, and elimination
health goals, and enable contribution to making health care of corruption in health care systems, both in the public
systems more effective, efficient, rational, safe, affordable systems and in the private health care industry, would be
and ethical. essential.
 Professionalism, Integrity and Ethics: Health workers
and managers shall perform their work with the highest
level of professionalism, integrity and trust and be
supported by a systems and regulatory environment that
enables this.
 Learning and Adaptive System: constantly improving
dynamic organization of health care which is knowledge
and evidence based, reflective and learning from the
communities they serve, the experience of implementa-
tion itself, and from national and international knowl-
edge partners.
Affordability: As costs of care rise, affordability, as

/e

distinct from equity, requires emphasis. Health care
costs of a household exceeding 10% of its total monthly

,8
consumption expenditures or 40% of its non-food
consumption expenditure- is designated catastrophic
health expenditures- and is declared as an unacceptable

rh
Fig.: (Newspaper): Draft of National Health Policy
level of health care costs. Impoverishment due to health
National Health Policy 2015 Draft: Goals & Principles care costs is of course, even more unacceptable.
a
•• Goal: The attainment of the highest possible level of good
health and well-being, through a preventive and promotive
ig
health care orientation in all developmental policies, and OPHTHALMOLOGY
universal access to good quality health care services without
nd

anyone having to face financial hardship as a consequence.

•• Key Policy Principles: 81. Ans:  e. B12
ha

 Equity: Public expenditure in health care, prioritizing [Ref: Harrison 19th/197 [Link]/[Link]; [Link]
the needs of the most vulnerable, who suffer the largest [Link]]
burden of disease, would imply greater investment in
“Centrocecal or cecocentral scotoma: Field defect involving
iC

access and financial protection measures for the poor.

Reducing inequity would also mean affirmative action to both the macula and the blind spot; seen in optic nerve disease,
reach the poorest and minimizing disparity on account such as Leber’s hereditary optic neuropathy, toxic or nutritional
optic neuropathies (said to be typical of vitamin B12 deficiency
PG

of gender, poverty, caste, disability, other forms of social

exclusion and geographical barriers. optic neuropathy), sometimes in optic neuritis” (doctorsjunction.
 Universality: Systems and services are designed to [Link])
cater to the entire population- not only a targeted sub-
Ophthalmologic Manifestations
group. Care to be taken to prevent exclusions on social
or economic grounds. Patient Centered & Quality of –– [Link]/index
Care: Health Care services would be effective, safe, and •• An unusual but well-documented manifestation of
convenient, provided with dignity and confidentiality cobalamin deficiency is optic neuropathy. This may present
with all facilities across all sectors being assessed, as a subacutely progressive decrease in visual acuity with
certified and incentivized to maintain quality of care. a cecocentral scotoma (i.e., a scotoma obscuring central
 Inclusive Partnerships: The task of providing health vision and enlarging the blind spot).
care for all cannot be undertaken by Government, •• The condition known as tobacco-ethanol amblyopia is
acting alone. It would also require the participation of similar, and may, at least in part, depend on cobalamin
communities – who view this participation as a means deficiency.
and a goal, as a right and as a duty. It would also require the “Damage to papillomacular fibers causes a cecocentral scotoma
widest level of partnerships with academic institutions, that encompasses the blind spot and macula. If the damage is
not for profit agencies and with the commercial private irreversible, pallor eventually appears in the temporal portion
sector and health care industry to achieve these goals. of the optic disc. Temporal pallor from a cecocentral scotoma
 Pluralism: Patients who so choose and when appropriate, may develop in optic neuritis, nutritional optic neuropathy, Answers
would have access to AYUSH care providers based on toxic optic neuropathy, Leber’s hereditary optic neuropathy, and &
Explanations
validated local health traditions. compressive optic neuropathy” (Harrison 19th/197)

537
 PGI Chandigarh Self-Assessment & Review: 2017–2013

82. Ans:  a. a wave- arises..., b. b wave - d/t..., c. b-wave... d. c

wave - representing....
[Ref: [Link] 6th/518-19; Parson 22nd/109-10]

“Electrophysiology is an essential adjunct in distinguishing

macular diseases and generalized retinal dysfunction . For
example, Best disease and adult onset vitelliform macular
dystrophy, both characterized by a similar fundus appearance
and normal electroretinogram (ERG), can be distinguished
by the electro-oculogram (EOG). We present a patient with Fig.: ([Link] 6th/519): Components of normal electroretinogram
vitelliform lesions in the macula and unexpected ERG results”- (ERG)
[Link] “The EOG indirectly measures the standing potential of the eye.
A normal light peak/dark trough ratio (Arden ratio) is greater
Electroretinogram than 1.8. In Best vitelliform macular dystrophy, the EOG is
–– [Link] 6th/518-19 abnormal with a reduced light peak/dark trough ratio almost
•• Normal record of ERG consists of the following waves always less than 1.5, typically between 1.0 and 1.3. The Arden
ratio stays constant with age for these individuals”

/e
 a-wave. It is a negative wave possibly arising from the
rods and cones.
b-wave. It is a large positive wave which is generated by 83. Ans:  a. It forms aqueous...., c. Ciliary processes...,

,8

Muller cells, but represents the acitivity of the bipolar d. Ciliary muscles....
cells [Ref: [Link] 6th/147-48 ; Parson 22nd/8-9 ]

rh
 c-wave. It is also a positive wave representing metabolic
activity of pigment epithelium. Ciliary Body
–– [Link] 6th/147-48
a
•• Both scotopic and photopic responses can be elicited in
•• Ciliary body is forward continuation of the choroid at ora
ERG. Foveal ERG can provide information about the
ig
serrata. In cut-section, it is triangular in shape.
macula.
•• The inner side of the triangle is divided into two parts:
•• Uses: ERG is very useful in detecting functional
nd

The anterior part (about 2 mm) having finger-like ciliary

abnormalities of the outer retina (up to bipolar cell layer), processes is called pars plicata and the posterior smooth
much before the ophthalmoscopic signs appear. However, part (about 4 mm) is called pars plana
ERG is normal in diseases involving ganglion cells and the
ha

•• Microscopic structure: From without inwards ciliary body

higher visual pathway, such as optic atrophy. consists of following five layers:
•• Clinical applications of ERG  Supraciliary lamina: It is the outermost condensed part
iC

 Diagnosis and prognosis of retinal disorders such as ret- of the stroma and consists of pigmented collagen fibres.
initis pigmentosa, Leber’s congenital amaurosis, retinal  Stroma of the ciliary body. It consists of connective tissue

ischaemia and other chorioretinal degenerations. of collagen and fibroblasts. Embedded in the stroma are
ciliary muscle, vessels, nerves, pigment and other cells.
PG

 To assess retinal function when fundus examination is

not possible, e.g., in the presence of dense cataract and Ciliary muscle occupies most of the outer part of ciliary
body. Ciliary muscle is supplied by parasympathetic
corneal opacity.
fibres through the short ciliary nerves.
 To assess the retinal function of the babies where
 Layer of pigmented epithelium. It is the forward
possibilities of impaired vision is considered.
continuation of the retinal pigment epithelium.
•• Abnormal ERG response. It is graded as follows:  Layer of non-pigmented epithelium.
 Subnormal response. b-wave response is subnormal  Internal limiting membrane.
in early cases of retinitis pigmentosa even before the •• Ciliary processes: These are finger-like projections from the
appearance of ophthalmoscopic signs. A subnormal ERG pars plicata part of the ciliary body. These are about 70-80
indicates that a large area of retina is not functioning. in number. Each process is about2-mm long and 0.5-mm in
 Extinguished response is seen when there is complete diameter. These are white in colour.
failure of rods and cones function e.g., advanced retinitis •• Structure: Each process is lined by two layers of epithelial
pigmentosa, complete retinal detachment, central retinal cells. The core of the ciliary process contains blood vessels
artery occlusion and advanced siderosis. and loose connective tissue. These processes are the site of
 A negative response indicates gross disturbances of the aqueous production.
retinal circulation. •• Functions of ciliary body. (i) Formation of aqueous
humour. (ii) Ciliary muscles help in accommodation.
Answers
&
Explanations

538
 November  | 2015

/e
Fig.: ([Link] 6th/147): Microscopic structure of the iris and ciliary body

,8
84. Ans:  a. Done for as..., b. Positive test-1..., c. Negative... 86. Ans:  a. Homocys..., d. Marfan..., e. Sulphite oxidase....
[Ref: [Link] 6th/392 ; Parson 22nd/478 ] [Ref: [Link] 6th/215-16 ; Parson 22nd/275 ]

Jones Dye Tests

–– [Link] 6th/392
•• These are performed when partial obstruction is suspected.
a rh Ectopia Lentis with Systemic Anomalies
–– [Link] 6th/215-16
Marfan’s syndrome: In this condition lens is displaced
1. 
ig
Jones dye tests are of no value in the presence of total upwards and temporally (bilaterally symmetrical)
obstruction. Homocystinuria. It is an autosomal recessive, inborn
2. 
nd

•• Jones primary test (Jones test I): It is performed to error of metabolism. In it the lens is usually subluxated
differentiate between watering due to partial obstruction of downwards and nasally.
the lacrimal passages from that due to primary hypersecretion Weil-Marchesani syndrome: Ocular features are
3. 
ha

of tears. Two drops of 2 percent fluorescein dye are instilled spherophakia, and forward subluxation of lens which may
in the conjunctival sac and a cotton bud dipped in 1 cause pupil block glaucoma.
Ehlers-Danlos syndrome. In it the ocular features are
4. 
iC

percent xylocaine is placed in the inferior meatus at the

opening of nasolacrimal duct. After 5 minutes the cotton subluxation of lens and blue sclera.
bud is removed and inspected. A dye-stained cotton bud Hyperlysinaemia:It is an extremely rare condition
5. 
indicates adequate drainage through the lacrimal passages occasionally associated with ectopia lentis.
PG

and the cause of watering is primary hypersecretion (further Stickler syndrome. Ectopia lentis is occasionally associated
6. 
investigations should aim at finding the cause of primary in this condition
hypersecretion). While the unstained cotton bud (negative Sulphite oxidase deficiency:Ectopia lentis is a universal
7. 
test) indicates either a partial obstruction or failure of ocular feature
lacrimal pump mechanism. To differentiate between these
Table: Ectopia Lentis
conditions, Jones dye test-II is performed.
•• Jones secondary test (Jones test II): When primary test Congenital lesion with Systemic Spontaneous
is negative, the cotton bud is again placed in the inferior anomalies
meatus and lacrimal syringing is performed. A positive
• Marfan’s syndrome (displaced upwards • Hypermature
test suggests that dye was present in the sac but could not
and temporally) Q cataract
reach the nose due to partial obstruction. A negative test
• Homocystinuria (subluxated • Buphthalmos
indicates presence of lacrimal pump failure.
downwards and nasally) Q
85. Ans:  a. Deposition..., c. Found in Wilson..., d. Deposition • Weil-Marchesani syndrome (forward • High myopia
under... subluxation) Q
• Ehler ‘ Danlos syndrome (subluxation • Staphyloma
[Ref: [Link] 6th/434 ; Parson 22nd/220 ] of lens and blue sclera) Q
“Kayser-Fleischer ring: It is a golden brown ring which occurs • Hyperlysinaemia • Intra-ocular tumors
Answers
due to deposition of copper under peripheral parts of the • Stickler syndrome • Uveitis . &
Descemet’s membrane of the cornea” ([Link] 6th/434) • Sulphite oxidase deficiency Explanations

539
 PGI Chandigarh Self-Assessment & Review: 2017–2013

87. Ans:  a . Amblyopia..., b. Angle of deviation..., e. May be Table ([Link] 6th/22): Tuning Fork Tests & Their Interpretation
associated....
Test Normal Conductive SN deafness
[Ref: [Link] 6th/348 ; Parson 22nd/ 428-29; Kanski 5th/ 543] deafness
Infantile Esotropia (Previously Called Congenital Rinne AC>BC (Rinne BC>AC (Rinne AC>BC
Esotropia) positive) negative)
–– [Link] 6th/348 Weber Not lateralized Lateralized to Lateralized to
•• Age of onset, is usually 1-2 months of age, but occur any time poorer ear better ear
in first 6 months of life. ABC Same as Same Reduced
•• Angle of deviation is usually constant & fairly large (> 30°), examiner’s asexaminer’s
•• Fixation pattern: Binocular vision does not develop & there
Schwabach Equal Lengthened Shortened
is alternate fixation in primary gaze and crossed fixation
in lateral gaze.
•• Amblyopia develops in 25-40% of cases
•• Associations include inferior oblique overaction (usually
developing after 1 year of age), dissociated vertical
deviation (DVD) in about 70-90% cases & latent horizontal

/e
nystagmus
•• Treatment: Surgery is treatment of choice

,8
 Time of surgery: Surgery should be done b/w 6 months
to 2 years (preferably before 1 yr of age)
 Amblyopia treatment by patching the normal eye should
always be done before performing the surgery
 Recession of both medial recti is preferred over unilateral
recess-resect procedure
a rh
ig
ENT
nd

88. Ans:  a. Rinne test is negative..., c. Lateralization of

ha

sound...., d. Negative Rinne... Fig.: ([Link] 6th/22): Tuning fork test. (A) Testing for air conduction.
(B) Testing for bone conduction. (C) Weber test
[Ref: [Link] 6th/22; L & T 10th/247-48]
iC

Rinne Test 89. Ans:  a. Bell palsy..., b. Parotid tu..., c. Guillain-Barré....

–– [Link] 6th/22 [Ref: [Link] 6th/94-96; L & T 10th/356-60 BDC 4th/[Link] 54;
•• A negative test(BC>AC) is seen in conductive deafness. A
PG

Harrison 19th/2577]
negative Rinne indicates a minimum air-bone gap of 15-20
“Facial paralysis occur in occlusion of anterior inferior cerebel-
dB
lar artery (lateral inferior pontine syndrome (Harrison 19th/2577)
•• A prediction of air-bone gap can be made if tuning forks of
“Bell’s palsy: It is the most common cause of acute LMN facial
256, 512 & 1024 Hz are used
palsy”
•• A Rinne test equal or negative for 256 Hz but positive for 512
Hz indicates air-bone gap of 20-30 dB Facial Paralysis
•• A Rinne test negative for 256 & 512 Hz but positive for 1024 –– [Link]/in/doctor
Hz indicates air-bone gap of 30-45 dB In an LMN lesion, the patient can’t wrinkle their forehead - the
•• A Rinne negative for all the three tunning forks of 256,512 final common pathway to the muscles is destroyed. The lesion
& 1024 Hz indicates air-bone gap of 45-60 dB must be either in the pons, or outside the brainstem (posterior
Weber Test fossa, bony canal, middle ear or outside skull).
–– [Link] 6th/22 Aetiology
•• It is lateralized to the worst ear in conductive deafness & to LMN
the better ear in sensorineural deafness •• Idiopathic (Bell’s palsy):
•• Lateralization of sound in Weber test with a tunning fork of  Pregnancy - 3x more common.
512 Hz implies a conductive loss of 15-20 dB in ipsilateral ear  Diabetes mellitus.
or a sensorineural loss in the contralateral ear •• Cerebrovascular disease (e.g., brainstem stroke).
Answers
&
Explanations

540
 November  | 2015

•• Iatrogenic:
 Local anaesthetic for dental treatment.
 Linezolid
•• Infective:
 Herpesvirus (type 1)
 Herpes zoster (Ramsay Hunt syndrome) - see below.
 HIV
 Epstein-Barr virus.
 Cytomegalovirus.
 Lyme disease (more likely if bilateral when responsible
for 36% of cases)
 Otitis media or cholesteatoma
•• Trauma:
 Fractures of the skull base.
 Forceps delivery
 Haematoma after acupuncture
•• Neurological:

/e
 Guillain-Barré syndrome.
 Mononeuropathy- e.g., due to diabetes mellitus, sarcoid- Fig.: ([Link] 6th/25): Types of tympanograms

,8
osis or amyloidosis.
•• Neoplastic: 91. Ans:  a. Voice..., b. Stridor..., d. Urgent tracheo...
 Posterior fossa tumours, primary and secondary.
[Ref: [Link] 6th/300;Logan & Turner 10th/182-83]

••
••
••
 Parotid gland tumours.
Hypertension in pregnancy and eclampsia.
Sarcoidosis
Sjögren’s syndrome and rheumatoid arthritis
a rh Bilateral Abductor Paralysis
–– [Link] 6th/300
•• As both the cords lie in median or paramedian position, the
ig
•• Melkersson-Rosenthal syndrome (recurrent facial palsy, airway is inadequate causing dyspnea & stridor but the voice
chronic facial oedema of the face and lips, and hypertrophy/ is good
nd

fissuring of the tongue) •• Tracheostomy: Many cases require tracheostomy as an

UMN emergency procedure or when they develop upper respiratory
ha

•• Cerebrovascular disease. tract infection

•• Intracranial tumours, primary and secondary. •• Transverse cordotomy
•• Multiple sclerosis. •• Partial arytenoidectomy
iC

•• Syphilis. •• Reinnervation procedures

•• HIV •• Thyroplasty II
•• Vasculitides “Woodman’s operation (External arytenoidectomy) is done in
b/l abductor paralysis (Logan & Turner 10th/183)
PG

90. Ans:  b. As type in..., c. Dome shaped..., d. Ad type in..., “Endoscopic laser arytenoidectomy & Isshiki type II thyro-
e. C type in eusta.... plasty is done for lateralization of cord (in bilateral abductor
paralysis)” (Dhingra 5th/318-19,362)
[Ref: [Link] 6th/25; L & T 10th/ 251]
A   — Normal 92. Ans:  c. Anterior superior....
As  — Reduced compliance at ambient pressure (otosclerosis).
[Ref: P.L. Dhingra 6th/185-86;5th/199-200 ; L & B 25th/331-32;CSDT
‘s’ stands for shallow tympanogram but remember for 11th/1256;Washington Manual of Surgery 5th/481;Sabiston 18th/494-95,
stiffness. 2143]
AD  — Increased compliance at ambient pressure (ossicular
“The condylar neck is the weakest part of the mandible and
discontinuity). ‘d’ stands for deep tympanogram. is the most frequent site of fracture” (L & B 25th/331)
Remember disruption of ossicular chain. “Many patients with mandibular fractures experience trauma to
B   — Flat or dome-shaped (fluid in middle ear). the inferior alveolar nerve (a branch of the trigeminal nerve),
C   — Maximum compliance at pressures more than –200 mm which runs through a canal within the body of the mandible and
H2O (negative pressure in middle ear), e.g. eustachian terminates in the lower lip as the mental nerve. These patients
tube obstruction or early stage of otitis media with may experience permanent numbness of the lower lip and teeth
effusion. on the affected side. Fractures of the coronoid process of the
mandible can result in trismus (inability to open the mouth)
Answers
&
Explanations

541
 PGI Chandigarh Self-Assessment & Review: 2017–2013

because the coronoid process normally passes beneath the •• Nonunion is characterized by pain and abnormal mobility
zygomatic arch with mouth opening” (Sabiston 18th/2143) following treatment.
Fracture of Mandible •• Radiographs demonstrate no evidence of healing and in later
stages show rounding off of the bone ends.
–– P.L. Dhingra 6th/185-86
•• The most likely cause for delayed union and nonunion is poor
•• Condylar fractures are the most common: They are
reduction and immobilization.
followed in frequency, by fracture of angle, body &
•• Infection is often an underlying cause. Carefully assess teeth
symphysis (Mnemonics CABS). Fractures of the ramus,
in the line of fractures for possible extraction or they may be
coronoid & alveolar processes are uncommon.
a nidus for infection.
•• In fracture of condyle, if fragments are not displaced, pain
& trismus are the main features & tenderness is elicited at
the site of fracture. If fragments are displaced, there is in
addition, malocclusion of teeth & deviation of jaw to the
opposite side on opening the mouth.
•• X-rays useful in mandibular fractures are PA view of the
skull (for condyle), right & left oblique view of mandible &
panorex view

/e
•• Both closed & open methods are used for reduction &
fixation of the mandibular fractures

,8
Fracture of Mandible
–– Washington Manual of Surgery 5th/481
•• Panorex radiographs are usually sufficient to diagnose
mandible fracture & visualize postreduction
•• Mandibualr fractures are not surgical emergencies & should
be addressed after stabilization of patient. Fixation within
3 days has been shown to be result in more favourable
a rh
Fig.: Fracture of mandible (Dingman’s classification). Condylar fracture
are the most common, followed by those of angle, body & symphysis
of mandible
ig
outcome
93. Ans:  a. Foul smelling..., c. Facial nerve involve..., d. May
•• Complications includes wound infection,malocculusion,
nd

cause hearing....
non-union, tooth loss, temporomandibular joint ankylosis
& paresthesis [Ref: Dhingra 6th/67-74; 5th/77,4th/68; L & T 10th/283-88]
ha

Fracture of Mandible CSOM

–– Sabiston 18th/494-95 –– Dhingra 6th/67-74
•• Imaging techniques frequently used to identify and classify •• Atticoantral variety: Facial weakness indicates erosion of
iC

mandibular fractures include plain films, panoramic facial canal (Dhingra 6th/73)
tomography (Panorex), and helical CT. A recent report •• Fallopian canal containing the facial nerve is at risk of
has demonstrated the overall superiority of helical CT over erosion in Atticoantral variety (L & T 10th/287)
PG

Panorex in identifying and decreasing interpretation error in Cholesteatoma is commonly a/w atticontral or unsafe of CSOM
patients with mandibular fractures
•• Reduction and fixation of mandibular fractures should Cholesteatoma
be accomplished as precisely and expeditiously as possible •• Cholesteatoma, stratified squamous epithelium in the
because malocclusion is a major long-term complication. middle ear or mastoid, occurs frequently in adults. This
•• Condylar and subcondylar mandible fractures are most is a benign, slowly growing lesion that destroys bone and
often treated by IMF alone. Surgical exposure of the normal ear tissue.
temporomandibular joint places the facial nerve at risk •• Theories of pathogenesis include traumatic implantation
and exposes the joint to possible injury and disfunction. and invasion, immigration and invasion through a
Mandibular Fracture: Delayed Union and Nonunion perforation, and metaplasia following chronic infection and
–– [Link] irritation.
•• Delayed union and nonunion occur in approximately 3% of •• On examination, there is often a perforation of the tympanic
fractures. membrane filled with cheesy white squamous debris. A
•• Delayed union is a temporary condition in which adequate chronically draining ear that fails to respond to appropriate
reduction and immobilization eventually produce bony union. antibiotic therapy should raise suspicion of a cholesteatoma.
•• Nonunion indicates a lack of bony healing between the •• Conductive hearing loss secondary to ossicular erosion is
segments that persists indefinitely without evidence of bone common. Surgery is required to remove this destructive
Answers healing unless surgical treatment is undertaken to repair the process.
&
Explanations
fracture.

542
 November  | 2015

Table ( Dhingra 6th/69, 5th/77): Differences b/w Atticoantral and •• Speckled erythroplakia

Tubotympanic type of CSOM •• Chronic hyperplastic candiiasis
Medium Risk Lesions
Feature Tubotympanic or Atticoantral or Unsafe
•• Oral submucous fibrosis
Safe type type
•• Syphilitic glossitis
Discharge Profuse, mucoid Scanty, purulent, foul- •• Sideropenic dysphagia (Paterson-Kelly syndrome)
smelling
Low Risk Lesions
Perforation Central Attic or marginal •• Oral lichen planus
Granulations Uncommon Common •• Discoid lupus erythematous
Polyp Pale Red and fleshy •• Discoid keratosis congenita
“Aphthous ulcer: It is a benign disease with unknown etiology”
Cholesteatoma Absent Present (Logan & Turner 10th /125)
Complications Rare Common “Ca oral tongue: It may also develop on a pre-existing
Audiogram Mild to moderate Conductive or mixed leukoplakia, long standing dental ulcer or syphilitic glossitis.
conductive deafness deafness Vast majority are squamous cell type” (Dhingra 5th/ 240)
“Lichen planus: It has no malignant potential” (Logan & Turner

/e
94. Ans:  a. Mucous..., b. Seen in floor..., c. Marsupialization..., 10th /126)
e. Arises from.... “Chronic ulcerative Lichen planus of oral mucosa can undergo
malignant change(but this is decidedly rare!)” (Neena Khanna

,8
[Ref: [Link] 6th/224-25; L & T 10th/127 ] 3rd/54)
Ranula “Papillomas occur most usually on the soft palate, anterior pillar
& buccal mucosa. They have no malignant potential” (Logan &
–– [Link] 6th/224
•• It is cystic translucent lesion seen in the floor of mouth on
one side of frenulum & pushing the tongue tip
•• It arises from the sublingual salivary gland due to obstruction
a rh
Turner 10th / 126)
“Fordyce’s spot are aberrant sebaceous glands present under
the buccal or labial mucosa & are considered normal” (Dhingra
ig
5th/233)
of its duct
“Keratoacanthoma (KA) is a common low grade (unlikely to
•• It can be either simple or cavernous. The simple variety is a
nd

metastasize or invade) skin cancer that is believed to originate

true retention cyst of one of the minor salivary glands (L &
from the neck of the hair follicle. Many pathologists consider
T 10th/127)
it to be a form of squamous cell carcinoma (SCC). KA is
•• Some ranulae extend into the neck(plunging type)
ha

commonly found on sun exposed skin, and often is seen on the

•• “Plunging ranula presents as a neck selling in submandibular
face, forearms and hands” (Neena Khanna 3rd/309)
region as the cyst extends into the neck posterior to the
iC

mylohyoid muscle” (ENT by Hazarika 4th/712)

•• Treatment is complete surgical excision if small or
marsupialization, if large. Often it is not possible to excise
Medicine
the ranual completely because of its thin wall or ramifications
PG

in various tissue planes 96. Ans:  c. Detection of both rif...

[Ref: [Link]/tb/topic/laboratory; [Link]: www.
95. Ans:  d. Apthus ulcer....
[Link]]
[Ref: Dhingra 6th/224-25,5th/238,233; Logan & Turner 10th /126 ]
What Tests are Being used for Molecular Detection of
Premalignant Lesion for Oral Cavity Cancer Drug Resistance
–– Dhingra 6th/224-25, 5th/238,233 •• Laboratory developed tests (LDT) – (1) DNA sequencing
•• Leukoplakia (“white patch”) is induced by the same factors & (2) Real-time PCR assays
(tobacco, alcohol) that cause carcinomas. The malignant •• Non-FDA approved tests (Research Use Only [RUO]) -(1)
potential of leukoplakia corresponds to the degree of Genotype® MTBDRplus and MTBDRsl- Hain Lifescience
cellular dysplasia seen on biopsy. (2)Cepheid GeneXpert® Xpert MTB/RIF
•• Erythroplakia (“red patch”) usually shows severe cellular “Genotype MTBDR plus (“HAIN test”) qNAA and hybridiza-
dysplasia and carries a 50% risk of malignant degeneration tion-based test use immobilized DNA probes on nitrocellulose
•• Melanosis & mucosal hyperpigmentation: may transform membranes (line probe assay [LPA]) & Colorimetric change in-
into malignant melanoma dicates hybridization & “Read” the bands to determine MTBC
or not and to detect resistance-associated mutations for RMP
Premalignant Conditions Associated with Oral cancer
and INH” ([Link])
–– L & B 25th/735 “Comparison of Xpert MTB/RIF with Line Probe Assay for Answers
High Risk Lesions Detection of Rifampin monoresistant M. tuberculosis” &
Explanations
•• Erythroplakia “The MTBDR plus line probe assay (LPA) and Xpert MTB/RIF

543
 PGI Chandigarh Self-Assessment & Review: 2017–2013

have been endorsed by the World Health Organization for the •• Measurement of mixed venous saturations
rapid diagnosis of drug-resistant tuberculosis. However, there is •• Estimation of diastolic filling of left heart (normal PCWP
no clarity regarding the superiority of one over the other” 2-12mmHg)
Use of Pulmonary Artery Catheterization
–– [Link]
•• Important information provided by a PAC catheter includes
the PCWP, assessment of left ventricular (LV) filling
pressure, CO, mixed venous oxygen saturation (SaO2), and
oxygen saturations in the right heart chambers to assess for
the presence of an intracardiac shunt.
•• Using these measurements, other variables can be derived,
including pulmonary or systemic vascular resistance and the
Fig.: ([Link]): Hain Test difference between arterial and venous oxygen content (see
images below). Obtaining CO and PCWP measurements
Background on Molecular Drug-Resistance (DR) Tests is the primary reason for inserting most PACs; therefore,
–– [Link]/tb/topic/laboratory understanding how they are obtained and what factors alter

/e
•• Recent advances in the understanding of the molecular basis their values is of prime importance.
or genetics of drug resistance have enabled development Pulmonary Artery Catheterisation and Pulmonary Artery
of rapid, DNA-based, molecular tests to detect mutations

,8
‘Wedge’ Pressure
associated with drug resistance.
–– Davidson 22nd/ 185-86
•• For hybridization assays such as the INNO-LiPA® Rif.
•• The CVP is usually an adequate guide to the filling pressures
TB (Innogenetics) and GenoType® MTBDR(plus) (Hain
LifeScience GmbH) line-probe assays, the region of a
gene associated with resistance is PCR amplified, and
the labeled PCR products hybridized to oligonucleotide
a rh of both sides of the heart. However, certain conditions,
such as pulmonary hypertension or right ventricular
dysfunction, may lead to raised CVP levels even in
the presence of hypovolaemia. In these circumstances,
ig
probes immobilized on a nitrocellulose strip. Mutations are
detected by lack of binding to wild-type probes or by binding it may be appropriate to insert a pulmonary artery
flotation catheter so that pulmonary artery pressure
nd

to probes specific for commonly occurring mutations.

•• Compared to culture-based DS tests, the MTBDR(plus) and pulmonary artery ‘wedge’ pressure (PAWP), which
line probe assay displays a pooled sensitivity of 0.98 and a approximates to left atrial pressure, can be measured.
•• Pulmonary artery catheters also allow measurement of
ha

pooled specificity of 0.99 for detecting rifampin resistance

in isolates or directly from clinical specimens cardiac output and sampling of blood from the pulmonary
artery (‘mixed venous’ samples), permitting continuous
Hain/Line Probe Assays
iC

monitoring of the mixed venous oxygen saturation (SvO2)

–– [Link] by oximetry. Measurement of SvO2 gives an indication
Advantages of the adequacy of cardiac output (and hence DO2)
•• Works on processed specimens in relation to the body’s metabolic requirements. It is
PG

•• Rapid Assay especially useful in low cardiac output states.

•• Improved instrumentation for analysis and documentation Hemodynamic Assessment
of results
–– Harrison 19th/ 1607
•• Used in laboratories now
•• Positioning of a balloon flotation (Swan-Ganz) catheter
Disadvantages in the pulmonary artery permits monitoring of LV filling
•• Multiple beacons needed to cover overlapping regions pressure; this technique is useful in patients who exhibit
•• Silent mutations may result in false predication of resistance hypotension and/or clinical evidence of CHF.
•• Not customizable by user •• Cardiac output can also be determined with a pulmonary
artery catheter. With the addition of intra-arterial pressure
97. Ans:  a. Measures right..., b. Measures left ventricular...,
monitoring, systemic vascular resistance can be calculated
c. Measure..., d. Inserted through...,
as a guide to adjusting vasopressor and vasodilator therapy.
[Ref: Harrison 19th/ 1607; Davidson 22nd/ 185-86; Manipal Surgery Pulmonary Artery Catheterization
4th/176; [Link]]
–– Harrison 19th/ 1760
USES of Swan-Ganz Catheter •• The use of pulmonary artery (Swan-Ganz) catheters in
–– [Link] patients with established or suspected cardiogenic shock(CS)
•• Continuous cardiac output monitoring is controversial. Their use is generally recommended for
Answers •• Central temperature monitoring measurement of filling pressures and cardiac output to
&
Explanations •• Measurement of pulmonary artery pressure (can also confirm the diagnosis and to optimize the use of IV fluids,
measure RA and RV pressures during insertion) inotropic agents, and vasopressors in persistent shock.

544
 November  | 2015

Pulmonary Artery Catheterization •• The characteristic symptoms of tabes are fleeting and
–– [Link] repetitive lancinating pains, primarily in the legs or less
The PAC is inserted percutaneously into a major vein (jugular, often in the back, thorax, abdomen, arms, and face. Ataxia
subclavian, femoral) via an introducer sheath. of the legs and gait due to loss of position sense occurs in
•• Right internal jugular vein (RIJ): Shortest and straightest half of patients.
path to the heart •• Paresthesias, bladder disturbances, and acute abdominal
•• Left subclavian: Does not require the PAC to pass and pain with vomiting (visceral crisis) occur in 15–30% of
course at an acute angle to enter the SVC (compared to the patients.
right subclavian or left internal jugular •• The cardinal signs of tabes are loss of reflexes in the legs;
•• Femoral veins: These access points are distant sites, impaired position and vibratory sense; Romberg’s sign;
from which passing a PAC into the heart can be difficult, and, in almost all cases, bilateral Argyll Robertson pupils,
especially if the right-sided cardiac chambers are enlarged. which fail to constrict to light but accommodate. Diabetic
Often, fluoroscopic assistance is necessary. Nevertheless, polyradiculopathy may simulate tabes.
these sites are compressible and may be preferable if the risk
99. Ans:  a. May present..., c. Smoking..., d. Nitrates are used...,
of hemorrhage is high.
e. CCBs are used for....
Swan-Ganz Catheterization
[Ref: Harrison 19th/1598 ;CMDT 2016/363 ; Braunwald’s Heart Diasease

/e
–– [Link]
8th/478]
•• A Swan-Ganz catheterization is a type of pulmonary artery

,8
catheterization procedure. Prinzmetal’s Variant Angina (PVA)
•• The procedure involves the insertion of a pulmonary artery –– Harrison 19th/1598,CMDT06/347 Braunwald’s Heart Diasease
catheter (PAC), also known as a Swan-Ganz catheter or 8th/478
right heart catheter, into the right side of the heart and into
the arteries that lead to the lungs.
•• The procedure itself is sometimes called “right heart
catheterization.” This is because it can measure the pressure
a rh
•• This syndrome is due to focal spasm of an epicardial
coronary artery, leading to severe myocardial ischemia. The
exact cause of the spasm is not well defined, but it may be
related to hypercontractility of vascular smooth muscle due
ig
of blood as it flows through the right side of your heart. It to vasoconstrictor
measures the pressure at three different places: right atrium, •• The vasospastic process almost always involves large
nd

pulmonary artery, and pulmonary capillaries. segments of the epicardial vessels at a single site, but at
different times other sites may be involved. The right
coronary artery is the most frequent site, followed by the
ha

left anterior descending coronary artery

•• Patients with no or mild fixed coronary obstruction tend
to experience a more benign course than patients with
iC

associated severe obstructive lesions

•• When the endothelium is dysfunctional, stimulation with
acetylcholine will fail to produce, or produce very little, nitric
PG

oxide. Thus, acetylcholine released by the parasympathetic

system at rest will simply cause contraction of the vascular
smooth muscle. It is potentially by this mechanism that
Prinzmetal’s angina occurs.
•• It usually occurs at rest and is associated with transient ST-
segment elevation.
•• Patients with variant angina are generally younger and have
fewer coronary risk factors (with the exception of cigarette
smoking) than patients with UA secondary to coronary
atherosclerosis.
98. Ans:  a. Lancinating..., b. Loss of proprio...., c. Sensory..., |
•• Many do not exhibit classic coronary risk factors except that
e. Sensory ataxia...
they are often heavy cigarette smokers patients with PVA
[Ref: Harrison 19th/2659 ;P J Mehta 20th/371-73] should be urged strongly to stop smoking
•• “Attacks of PVA tend to cluster between midnight and 8 am,
Tabes Dorsalis
and sometimes occur in clusters of two or three within 30 to
–– Harrison 19th/2659 60 minutes”- Braunwald’s Heart Diasease 8th/478
•• The classic syphilitic syndromes of tabes dorsalis and •• ECG finding will more often show ST segment elevation
meningovascular inflammation of the spinal cord are now than ST depression. Elevation ST-segment in II, III and aVf. Answers
less frequent than in the past but must be considered in the •• Nitrates and calcium channel blockers are the main &
differential diagnosis of spinal cord disorders. treatments for patients with variant angina. Aspirin may
Explanations

545
 PGI Chandigarh Self-Assessment & Review: 2017–2013

actually increase the severity of ischemic episodes, possibly Revision of the Jones Criteria for the Diagnosis of Acute
as a result of the sensitivity of coronary tone to modest Rheumatic Fever: 2015
changes in the synthesis of prostacyclin. The response to •• The famous Jones criteria for diagnosis of Acure Rhemaric
beta blockers is variable. Coronary revascularization may Fever are recently revised in 2015 by AHA with emphasis on
be helpful in patients who also have discrete, flow-limiting, doppler echocardiogarphy for involvement of heart.
proximal fixed obstructive lesions •• It is the first substantial revision to the Jones Criteria by the
American Heart Association since 1992.
100. Ans:  a. Polyarthritis..., c. Monoarthritis in ...., •• It is technology driven (ECHO) and focuses on epidemi-
d. Echocardiography..., e. Echocardiography.... ological differences in high-risk and low-risk populations.
[Ref: [Link] [Link] •• As per epidemiological data, cases are divided into:
 Low risk should be defined as having an ARF incidence

Revision of the Jones Criteria for the Diagnosis of Acute <2 per 100 000 school-aged children (usually 5–14 years
Rheumatic Fever in the Era of Doppler Echocardiography old) per year. Or an allege prevalence of RHD of ≤1 per
1000 population per year.
–– [Link]
 Children not clearly from a low-risk population are
•• Revised Jones criteria, low-risk populations: Major and
at moderate to high risk depending on their reference
minor criteria are as follows:
population.

/e
 Major criteria: carditis (clinical and/or subclinical),
arthritis (polyarthritis), chorea, Erythema marginatum,
and subcutaneous nodules Revised Jones Criteria(2015)

,8
 Minor criteria: olyarthralgia, fever (≥38.5° F), sedimen- A. Diagnosis
tation rate ≥60 mm and/or C-reactive protein (CRP) ≥3.0
  For all patient populations with evidence of preceding GAS

rh
mg/dl, and prolonged PR interval (unless carditis is a ma-
infection
jor criterion)
•• Revised Jones criteria, moderate- and high-risk popula-
a   Initial ARF-2 Major or 1 major plus 2 minor
tions: Major and minor criteria are as follows:
ig
 Major criteria: Carditis (clinical and/or subclinical), ar-   Recurrent ARF-2 Major or 1 major and 2 minor or 3 minor
thritis (monoarthritis or polyarthritis, or polyarthralgia),
nd

B. Major Criteria
chorea, Erythema marginatum, and subcutaneous nod-
ules Low-risk populations Moderate-and high-risk
 Minor criteria: fever (≥38.5° F), sedimentation rate ≥30 population
ha

mm and/or CRP ≥3.0 mg/dl, and prolonged PR interval 1. Carditis 1. Carditis

(unless carditis is a major criterion) ƒƒ Clinical and/or ƒƒ Clinical and/or subclinical
•• ARF diagnosis (initial episode): The diagnosis of an initial subclinical carditis carditis
iC

episode of ARF requires two major criteria, or one major

2. Arthritis 2. Arthritis
plus two minor criteria.
ƒƒ Polyarthritis ƒƒ Monoarthritis or
polyarthritis
PG

Carditis: Diagnosis in the Era of Widely Available Echocar-

ƒƒ Polyarthralgia
diography:
3. Chorea 3. Chorea
•• Echocardiography with Doppler should be performed in 4. Erythema marginatum 4. Erythema marginatum
all cases of confirmed and suspected ARF (Class I; Level of
Evidence B). 5. Subcutaneous nodules 5. Subcutaneous nodules
•• It is reasonable to consider performing serial echocardi- C. Minor criteria
ography/ Doppler studies in any patient with diagnosed or
suspected ARF even if documented carditis is not present Low-risk populations Moderate-and high-risk
on diagnosis (Class IIa; Level of Evidence C). populations
•• Echocardiography/Doppler testing should be performed
1. Polyarthralgia 1. Monoarthralgia
to assess whether carditis is present in the absence of
auscultatory findings, particularly in moderate- to high- 2. Fever (>38.5°) 2. Fever (>38°C)
risk populations and when ARF is considered likely (Class
I; Level of Evidence B). 3. ESR ≥60 mm in 1st hour and/ 3. ESR ≥30 mm/h and/or CRP >3.0
•• Echocardiography/Doppler findings not consistent with or CRP>3.0 mg/dl mg/dL
carditis should exclude that diagnosis in patients with a
4. Prolonged PR interval, after accounting for age variability
heart murmur otherwise thought to indicate rheumatic
(unless carditis is a major criterion) in all population.
Answers carditis (Class I; Level of Evidence B).
&
Explanations

546
 November  | 2015

or imminent crisis. This generally results in a sudden rise in

blood pressure and a slowing of the pulse.
Signs of increased ICP include decreasing level of
consciousness, paralysis or weakness on one side of the body,
and a blown pupil, one that fails to constrict in response
to light or is slow to do so.
Cushing’s triad, a slow heart rate with high blood pres-
sure and respiratory depression is a classic manifestation
of significantly raised ICP.
Anisocoria, unequal pupil size, is another sign of serious
traumatic brain injury
Abnormal posturing, a characteristic positioning of the
limbs caused by severe diffuse injury or high ICP, is an
ominous
Cushing Reaction
–– Guyton 11th/213
•• The so-called Cushing reaction is a special type of CNS

/e
ischemic response that results from increased pressure of
the cerebrospinal fluidQ around the brain in the cranial

,8
vault. For instance, when the cerebrospinal fluid pressure
rises to equal the arterial pressure, it compresses the whole
brain as well as the arteries in the brain and cuts off the blood
a rh supply to the brain. This initiates a CNS ischemic response
that causes the arterial pressure to rise. When the arterial
pressure has risen to a level higher than the cerebrospinal
ig
fluid pressure, blood will flow once again into the vessels of
the brain to relieve the brain ischemia.
nd

•• Ordinarily, the blood pressure comes to a new equilibrium

level slightly higher than the cerebrospinal fluid pressure,
thus allowing blood to begin again to flow through the
ha

brain. The Cushing reaction helps protect the vital centers

of the brain from loss of nutrition if ever the cerebrospinal
fluid pressure raise high enough to compress the cerebral
iC

arteries.
“Cushing’s triad is the triad of widening pulse pressure
(rising systolic, declining diastolic), change in respiratory
PG

pattern (irregular respirations), and bradycardia. It is sign of

increased intracranial pressure, and it occurs as a result of the
Cushing reflex” (wikipedia)

102. Ans:  c. Carrier state..., d. Majority progress....

[Ref: Harrison 19th/2013,2018 ; Robbins(SAE) 9th/835-36 ;CMDT
2016/673]
101. Ans:  b. Decrease..., d. Hyperte..., e. Decreased.... “Hepatitis A & E never cause chronic hepatitis except HEV in
[Ref: Guyton 11th/213;CSDT 11th/890; Harrison 19th/1778-79;Manipal immunocompromised hosts & pregnant females” (Robbins(SAE)
Surgery 4th/1038] 9th/835)
“Cushing triad of increased ICP: Bradycardia, hypertension “Reported extrahepatic manifestations include arthritis,
& irregular respiration” (Manipal Surgery 4th/1038) pancreatitis, and a variety of neurologic complications. In
“Blood pressure elevation accompanied by bradycardia and endemic regions, the mortality rate is high (10–20%) in
respiratory slowing classically results from raised intracranial pregnant women and correlates with high levels of HEV RNA
pressure. This “Cushing response,” however, usually appears only in serum and gene mutations that lead to reduced expression of
when intracranial hypertension is severe” (CSDT 11th/890) progesterone receptors, and the risk of hepatic decompensation
is increased in patients with underlying chronic liver disease”
Features of Increased ICT (CMDT 2016/673) Answers
Loss of the normal autoregulation of blood pressure and pulse, Illness generally is self-limited (no carrier state)”- (CMDT &
called the Cushing’s reflex, is a hallmark of severe brain injury 2016/673)
Explanations

547
 PGI Chandigarh Self-Assessment & Review: 2017–2013

“The most feared complication of viral hepatitis is fulminant encephalopathy that may evolve to deep coma. The liver is usually
hepatitis (massive hepatic necrosis); fortunately, this is a rare small and the PT excessively prolonged. The combination of
event. Fulminant hepatitis is seen primarily in hepatitis B, D, rapidly shrinking liver size, rapidly rising bilirubin level, and
and E, but rare fulminant cases of hepatitis A marked prolongation of the PT, even as aminotransferase levels
Fulminant hepatitis is hardly ever seen in hepatitis C, but fall, together with clinical signs of confusion, disorientation,
hepatitis E, can be complicated by fatal fulminant hepatitis somnolence, ascites, and edema, indicates that the patient has
in 1–2% of all cases and in up to 20% of cases in pregnant hepatic failure with encephalopathy” (Harrison 19th/2018)
women. Patients usually present with signs and symptoms of

Table (Harrison 19th/2013): Clinical and Epidemiologic Features of Viral Hepatitis

Feature HAV HBV HCV HDV HEV

Incubation (days) 15–45, mean 30 30–180, mean 60–90 15–160, mean 50 30–180, mean 60–90 14–60, mean 40
Onset Acute Insidious or acute Insidious Insidious or acute Acute
Age preference Children, young Young adults (sexual and Any age, but more Any age (similar to Young adults

/e
adults percutaneous), babies, common in adults HBV) (20–40 years)
toddlers

,8
Transmission
Fecal-oral – – – +++
+++
Percutaneous
Perinatal
Unusual
–
+++
+++
a +++
±
rh +++
+
–
–
ig
Sexual ± ++ ± ++ –
nd

Clinical
Severity Mild Occasionally severe Moderate Occasionally severe Mild
ha

Fulminant 0.1% 0.1–1% 0.1% 5–20% 1–2%

Progression to None Occasional (1–10%) (90% of Common (85%) Common None
chronicity neonates)
iC

Carrier None 0.1–30% 1.5–3.2% Variable None

Cancer None +(Neonatal infection) + ± None
PG

Prognosis Excellent Worse with age, debility Moderate Acute, good Chronic, Good
poor
Prophylaxis Ig, inactivated HBIG, recombinant vaccine None HBV vaccine (none Vaccine
vaccine for HBV carriers)
Therapy None Interferon Pegylated interferon Interferon ± None
Lamivudine plus ribavirin, telaprevir,
Adefovir boceprevir
Pegylated interferon
Entecavir
Telbivudine
Tenofovir

Answers
&
Explanations

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 November  | 2015

103. Ans:  b. Renal osteodys..., d. Peripheral..., e. Small.... “Anaemia, metabolic acidosis, hyperphosphatemia, hypocalcemia
& hyperkalemia can occur with both acute & chronic renal failure”
[Ref: Harrison 19th/ 1808-20, 18th/ 2310-20; CMDT 09 / 797-807]
(CMDT 06 / 908)
Anaemia & Raised Creatinine are also Found in ARF
The term chronic renal failure applies to the process of 104. Ans:  a. Show cutaneous..., b. High CD4..., d. May be
continuing significant irreversible reduction in nephron associated...
number, and typically corresponds to CKD stages 3–5
“The first step in evaluating a patient with renal failure is [Ref: Harrison 19th/ 2205-12; Robbins(SAE) 9th/693-94 ;CMDT
2016/292-93]
to determine if the disease is acute or chronic. If review of
laboratory records demonstrates that the rise in blood urea “Sarcoidosis is linked with clinical anergy and other evidence
nitrogen and creatinine is recent, this suggests that the process of diminished cellular immunity ([Link])
is acute. However, previous measurements are not always “Regarding the tuberculin skin test, patients with sarcoidosis
available. Findings that suggest chronic kidney disease have impaired delayed-type immune reactions. Two thirds of
include anemia, evidence of renal osteodystrophy (radiologic patients with systemic sarcoidosis have cutaneous anergy to
or laboratory), and small scarred kidneys. However, anemia the tuberculin and other skin tests. It is not known if cutaneous
may also complicate ARF, and renal size may be normal anergy is frequent in patients with cutaneous lesions of
or increased in several chronic renal diseases (e.g., diabetic sarcoidosis with little or no systemic involvement” (emedicine.

/e
nephropathy, amyloidosis, polycystic kidney disease, HIV [Link])
associated nephropathy)” (Harrison 19th/1805)
“Bronchoalveolar lavage fluid in sarcoidosis is usually charac-

,8
“Anemia develops rapidly in ARF and is usually multifactorial
terized by an increase in lymphocyte & a high CD4/CD8 ratio”
in origin. Contributing factors include impaired erythropoiesis,
(CMDT 2016/293)
hemolysis, bleeding, hemodilution, and reduced red cell
survival time” (Harrison 19th/1810)
Cardiopulmonary complications of ARF include arrhythmias,
pericarditis and pericardial effusion, and pulmonary edema”
(Harrison 19th/1809)
a rh
“The use of the lymphocyte markers CD4 and CD8 can be used
to determine the CD4/CD8 ratio of these increased lymphocytes
in the BAL fluid. A ratio of > 3.5 is strongly supportive of
sarcoidosis but is less sensitive than an increase in lymphocytes
ig
alone” (Harrison 17th/2140)
CRF: CMDT 09/797-807: States
“Sarcoidosis: Intra-alveolar & interstitial accumulation of CD4+
nd

•• Pericardial effusions can occur with azotemia, and a

pericardial friction rub can be present. Effusions may result T cells, resulting in CD4: CD8 ratios ranging from 5:1 to 15:1”
in cardiac tamponade (Robbins 9th/693)
ha

•• Elevated BUN and creatinine are present, though these “Schauman & asteroid bodies :Although characteristic,
elevations do not in themselves distinguish acute from these cells are not pathognomic of sarcoidosis because they
chronic renal failure. Anemia can occur as a result of may be encountered in other granulomatous diseases (e.g.,
iC

decreased erythropoietin production. tuberculosis)” (Robbins 9th/693)

•• Progressive azotemia over months to years.
•• Symptoms and signs of uremia when nearing end-stage Sarcoidosis
PG

disease. •• The granuloma is the pathologic hallmark of sarcoidosis

•• Hypertension in the majority. •• Sarcoidosis is an inflammatory disease characterized by the
•• Isosthenuria and broad casts in urinary sediment are presence of noncaseating [Link] disease is often
common. multisystem and requires the presence of involvement in
•• Bilateral small kidneys in ultrasound are diagnostic two or more organs for a specific diagnosis.
•• With uremia, pericarditis may develop. •• Either direct vascular involvement or the consequence of
•• The anemia of chronic renal failure is characteristically fibrotic changes in the lung can lead to pulmonary arterial
normochromic and normocytic hypertension. In sarcoidosis patients with end-stage fibrosis
•• Peripheral neuropathies manifest themselves as sensorim- awaiting lung transplant, 70% will have pulmonary arterial
otor polyneuropathies (stocking and glove distribution) and hypertension.
isolated or multiple isolated mononeuropathies. •• The peribronchial thickening seen on CT scan seems
CRF to explain the high yield of granulomas from bronchial
–– Harrison 19th/ 1818-19 biopsies performed for diagnosis.
•• A normocytic, normochromic anemia is observed as early as •• A positive gallium scan can support the diagnosis if
stage 3 CKD and is almost universal by stage 4. The primary increased activity is noted in the parotids and lacrimal
cause in patients with CKD is insufficient production of glands (Panda sign) or in the right paratracheal and left hilar
erythropoietin (EPO) by the diseased kidneysd and urine area (lambda sign)
chemistry, abnormal imaging studies). •• The Kviem-Siltzbach procedure is a specific diagnostic test Answers
•• Peripheral neuropathy usually becomes clinically evident for sarcoidosis &
Explanations
after the patient reaches stage 4 CKD

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 PGI Chandigarh Self-Assessment & Review: 2017–2013

105. Ans:  a. 9... b. 10.... Duchenne Muscular Dystrophy (DMD)

•• DMD is the most severe and the most common form of
[Ref: Hutchison’s clinical Method 21th/249; P.J. Mehta 16th/230]
muscular dystrophy
Reflex Afferent Efferent •• DMD becomes clinically manifest by the age of 5 years, with
Light Reflex Optic Nerve Occulomotor nerve weakness leading to wheelchair dependence by 10 to 12
years of age, and progresses relentlessly until death by the
Accomodation Reflex Optic Nerve Occulomotor nerve early twenties.
Gag Reflex Glossopharyngeal Vagus •• Histopathologic abnormalities common to DMD and BMD
nerve include (1) variation in fiber size (diameter) due to the
Ciliospinal Reflex Cervical nerve Cervical portion of presence of both small and enlarged fibers, sometimes with
spinal cord fiber splitting; (2) increased numbers of internalized nuclei
(beyond the normal range of 3% to 5%); (3) degeneration
necrosis, and phagocytosis of muscle fibers; (4) regeneration of
106. Ans:  a. Mental impairmen... b. ↑Serum..., c. Cardiomy... muscle fibers; and (5) proliferation of endomysial connective
[Ref: Harrison 19th/ 462-e; Robbins 8th/1268-69; Nelson 18th/ 2540, tissue
2554, 2565] •• Histochemical reactions sometimes fail to identify distinct
fiber types in DMD. In later stages, the muscles eventually
“DMD: Serum CK levels are invariably elevated to between

/e
become almost totally replaced by fat and connective tissue.
20 and 100 times normal. The levels are abnormal at birth but
•• Cardiac involvement, when present, consists of interstitial
decline late in the disease because of inactivity and loss of muscle

,8
fibrosis, more prominent in the subendocardial layers.
mass” (Harrison 18th/ 3491)
Despite the clinical evidence of CNS dysfunction in DMD,
“Duchenne Muscular Dystrophy: This X-linked recessive disorder,
no consistent neuropathologic abnormalities have been
sometimes also called pseudohypertrophic muscular dystrophy,
has an incidence of ~30 per 100,000 live-born males”
Table (Harrison 19th/ 462-e ): Progressive Muscular Dystrophies
a rh described.
ig
Type Inheritance Defective Onset Age Clinical Features Other Organ Systems
Gene/Protein Involved
nd

Duchenne’s XR Dystrophin Before 5 Progressive weakness of girdle muscles Cardiomyopathy

years Unable to walk after age 12 Mental impairment
Progressive kyphoscoliosis
ha

Respiratory failure in 2d or 3d decade

Becker’s XR Dystrophin Early Progressive weakness of girdle muscles Cardiomyopathy
childhood Able to walk after age 15
iC

to adult Respiratory failure may develop by 4th decade

107. Ans:  a. Occur..., b. Uroporp..., c. Abdominal..., d. ↑ Porpho •• The peripheral neuropathy is due to axonal degeneration
PG

(rather than demyelinization) and primarily affects motor

[Ref: Harrison 19th/ 2521-30, 18th/ 3167-74; CMDT 2016/1655-56;
Nelson 18th/645-46]
neurons. Motor neuropathy affects the proximal muscles
initially, more often in the shoulders and arms. The course
“AIP: Patients show intermittent abdominal pain of varying and degree of involvement are variable and sometimes may
severity, and in some instances it may so simulate acute abdomen be focal and involve cranial nerves.
as to lead to exploratory laparotomy. Because the origin of the •• Abdominal tenderness, fever, and leukocytosis are usually
abdominal pain is neurologic, there is an absence of fever and absent or mild because the symptoms are neurologic rather
leukocytosis” (CMDT 2016/1655) than inflammatory.
“The diagnosis can be confirmed by demonstrating an •• Nausea; vomiting; constipation; tachycardia; hypertension;
increased amount of porphobilinogen in the urine during an mental symptoms; pain in the limbs, head, neck, or chest;
acute attack” (CMDT 2016/1655) muscle weakness; sensory loss; dysuria; and urinary
Acute Intermittent Porphyria (AIP) retention are characteristic. Tachycardia, hypertension,
–– Harrison Harrison 19th/ 2526 restlessness, tremors, and excess sweating are due to
•• Because the neurovisceral symptoms rarely occur before sympathetic overactivity.
puberty and are often nonspecific, a high index of suspicion •• Mental symptoms such as anxiety, insomnia, depression,
is required to make the diagnosis. disorientation, hallucinations, and paranoia can occur in
•• Abdominal pain, the most common symptom, is usually acute attacks. Seizures can be due to neurologic effects or to
Answers steady and poorly localized but may be cramping. Ileus, hyponatremia.
&
Explanations
abdominal distention, and decreased bowel sounds are
common.

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 November  | 2015

Table (Harrisonn 19th/2522): Human Porphyrias-Major Clinical and Laboratory Features

Porphyria Deficient Inheri- Prin-cipal En-zyme Increased Porphyrin Precursors and/or Porphyrins
Enzyme tance Symp-toms Acti-vity
% of
NV or CP Erythrocytes Urine Stool
Normal
Hepatic Porphyrias
5-ALA ALA- AR NV ~5 Zn-proto- ALA, Coproporphyrin III —
dehydratase- dehydratase porphyrin
deficient
porphyria (ADP)
Acute HMB-synthase AD NV ~50 — ALA, PBG, Uroporphyrin —
intermittent
porphyria (AIP)
Porphyria URO- AD CP ~20 — Uroporphyrin, Isocoproporphyrin
cutanea tarda decarboxylase 7-carboxylate porphyrin
(PCT)

/e
Hereditary COPRO- AD NV & CP ~50 — ALA, PBG, Coproporphyrin III
coproporphyria oxidase Coproporphyrin III

,8
(HCP)
Variegate PROTO- AD NV & CP ~50 — ALA, PBG, Coproporphyrin III
porphyria (VP) oxidase Coproporphyrin III Protoporphyrin
Erythropoietic Porphyrias
Congenital
erythropoietic
URO-synthase AR CP 1–5
a rh
Uropor
phyrin I
Uroporphyrin I
Coproporphyrin I
Coproporphyrin I
ig
porphyria (CEP) Coproporphyrin I
Erythropoietic Ferrochelatase ADa CP ~20–30 Proto-porphyrin — Protoporphyrin
nd

protoporphyria
(EPP)
ha

Abbreviations: AD, autosomal dominant; ALA, 5’-aminolevulinic acid; AR, autosomal recessive; CP, cutaneous photosensitivity; COPRO, copro-
porphyrinogen; HMB, hydroxymethylbilane; ISOCOPRO, isocoproporphyrin; NV, neurovisceral; PBG, porphobilinogen; PROTO, protoporphy-
rinogen; URO, uroporphyrinogen.
iC

108. Ans:  a. Bilirubin..., b. Prothrombi..., e. Absence... Table (Harrison 19th/1995): Child-Pugh Classification of Cirrhosis
[Ref: Harrison 19th/1994-95 ;;CMDT 2016/693 ; L&B 25th/1083] Factor Units 1 2 3
PG

Serum bilirubin µmol/L <34 34–51 >51

Table ( Schwartz): Revised Child Classification of Clinical Severity of mg/dL <2.0 2.0–3.0 >3.0
Cirrhosis Serum albumin g/L >35 30–35 <30
g/dL >3.5 3.0–3.5 <3.0
Factor A B C
Prothrombin time seconds 0–4 4–6 >6
Nutritional statusQ Excellent Good Poor prolonged <1.7 1.7–2.3 >2.3
INR
AscitesQ None Minimal, Moderate to
controlled severe Ascites None Easily Poorly
controlled controlled
EncephalopathyQ None Minimal, Moderate to
controlled severe Hepatic None Minimal Advanced
encephalopathyQ
Serum bilirubin (mg/dL)Q <2 2–3 >3
Note:  The Child-Pugh score is calculated by adding the scores of
Serum albumin (g/dL)Q >3.5 2.8–3.5 <2.8 the five factors and can range from 5–15. Child-Pugh class
is either A (a score of 5–6), B (7–9), or C (10 or above).
Prothrombin time (% of >70 40–70 <40
Decompensation indicates cirrhosis with a Child-Pugh
control)Q
score of 7 or more (class B). This level has been the accepted
criterion for listing for liver transplantation Answers
&
Explanations

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 PGI Chandigarh Self-Assessment & Review: 2017–2013

109. Ans:  b. Most common... ic arortic aneurysms is evolving toward endoluminal approach-
es using stent grafts (expandable wire frames covered by a cloth
[Ref: Harrison 19th/ 1639-40;CMDT 2016/476-78;Robbins 7th/531-32]
sleeve) rather than surgery for some patients” (Robbins 7th/532)
“Operative repair of the aneurysm with insertion of a prosthetic “Approx. 40-60% pt. have suitable anatomy & are candidate
graft or endovascular placement of an aortic stent graft is for endoluminal repair with stent placement” (Fisher Mastery of
indicated for abdominal aortic aneurysms of any size that Surgery 5th/2052)
are expanding rapidly or are associated with symptoms. For
Abdominal Aortic Aneurysm (AAA)
asymptomatic aneurysms, abdominal aortic aneurysm repair
–– Harrison 19th/ 1639-40
is indicated if the diameter is >5.5 cm. In randomized trials of
•• 90% of abdominal aortic aneurysm (AAA) of size > 4cm in
patients with abdominal aortic aneurysms <5.5 cm, there was
diameter is due to atherosclerosis.
no difference in the long-term (5- to 8-year) mortality rate
•• Male are more frequently affected than female.
between those followed with ultrasound surveillance and those
•• An abdominal aortic aneurysm commonly produces no
undergoing elective surgical repair. Thus, serial noninvasive
symptoms. It is usually detected on routine examination as a
follow-up of smaller aneurysms (<5 cm) is an alternative to
palpable, pulsatile, expansile, and nontender mass, or it is an
immediate repair. The decision to perform an open surgical
incidental finding during an abdominal x-ray or ultrasound
operation or endovascular repair is based in part on the vascular
study performed for other reasons.
anatomy and comorbid conditions. Endovascular repair of
•• As abdominal aortic aneurysms expand, however, they
abdominal aortic aneurysms has a lower short-term morbidity
may become painful. Some patients complain of strong

/e
rate but a comparable long-term mortality rate with open
pulsations in the abdomen; others experience pain in the
surgical reconstruction. Long-term surveillance with CT or MR
chest, lower back, or scrotum. Aneurysmal pain is usually

,8
aortography is indicated after endovascular repair to detect leaks
a harbinger of rupture and represents a medical emergency
and possible aneurysm expansion” (Harrison 19th/1640)
•• The aneurysm most commonly arises below the level of
“Majority are asymptomatic & often diagnosed incidently.
renal artery.
Many have pulsatile epigastric mass. Rupture cause severe
central abdominal & lumbar back pain, variable psoas spasm,
sometime pain in lower limb d/t compression of lumbar or
sciatic nerve root” (Oxfore Textbook of Surgery/379-80)
a rh •• Prognosis of abdominal aortic aneurysm is depends on size
of the aneurysm and the severity of co-existing coronary
artery and cerebrovascular disease. Most of the time they
are asymptomatic
ig
“Obstruction of a vessel, particularly of the iliac, renal, mesen-
•• Beta blocker decreases the perioperative cardiovascular
teric, or vertebral branches that supply the spinal cord leading to
morality.
ischemic tissue injury. The treatment of abdominal and thorac-
nd

110. Ans:  a. Adrenalec..., b. Pituitary... c. Stereotactic pit..., d. Surgical removal....

ha

[Ref: Harrison 19th/2271-73,2313-16 ; Davidson 22nd/775;CMDT 2016/1152-56]

It is a case of cushing’s disease
iC
PG

Answers
& Fig.: (Davidson 22nd/775): Determining the cause of confirmed Cushing’s syndrome.(ACTH = adrenocorticotrophic hormone; AIMAH = ACTH-
Explanations independent macronodular adrenal hyperplasia; BIPSS = bilateral inferior petrosal sinus sampling; CRH = corticotrophin-releasing hormone;
HDDST = high-dose dexamethasone suppression test; PPNAD = primary pigmented nodular adrenal disease)

552
 November  | 2015

•• Prophylactic radiation therapy may be indicated to prevent

the development of Nelson’s syndrome after adrenalectomy
Cushing Disease
–– CMDT 2016/1154
•• It is best treated by transsphenoidal selective resection of
the pituitary adenoma. After pituitary surgery, the rest of
the pituitary usually returns to normal function; however,
the pituitary corticotrophs remain suppressed and require
6–36 months to recover normal function.
•• Hydrocortisone or prednisone replacement therapy is
necessary in the meantime. Patients who do not have a
remission(or who have a recurrence) may be considered for
treatment with cabergoline 0.5–3.5 mg orally twice weekly,
which was successful in 40% of patients in one small study.
•• Laparoscopic adrenalectomy should be offered to
unresponsive patients.

/e
•• Another treatment option for patients with ACTH-secreting
pituitary tumors is stereotactic pituitary radiosurgery
(gamma knife or cyberknife), which normalizes urine free

,8
cortisol in two-thirds of patients within 12 months.
•• Pituitary radiosurgery can also be used to treat Nelson
syndrome, the progressive enlargement of ACTH-secreting

rh
Fig.: (Harrison 19th/2273): Management of Cushing’s syndrome. ACTH,
adrenocorticotropin hormone; MRI, magnetic resonance imaging.*, pituitary tumors following bilateral adrenalectomy.
Not usually required.
a
111. Ans:  b. Polyarteritis....
Cushing’s Disease: Management
ig
[Ref: Harrison 17th/2118-2121; Robbins 9th/506; 7th/537;Davidson
–– Davidson 22nd/775
22nd/713]
nd

•• Trans-sphenoidal surgery carried out by an experienced

surgeon with selective removal of the adenoma is the “PAN is a systemic vasculitis of small or medium-sized
treatment of choice, with approximately 70% of muscular arteries (but not arterioles, capillaries, or venules),
typically involving renal and visceral vessels but sparing the
ha

patients going into immediate remission. Around

20% of patients suffer a recurrence, often years later, pulmonary circulation. Classic PAN occurs as segmental
emphasising the need for life-long follow-up. transmural necrotizing inflammation of arteries of medium to
small size, in any organ with the possible exception of the lung,
iC

•• Laparoscopic bilateral adrenalectomy performed by an

expert surgeon effectively cures ACTH-dependent and most frequently kidneys, heart, liver, and gastrointestinal
Cushing’s syndrome, but in patients with pituitary tract.” (Robbins 9th/509)
“Microscopic polyangiitis (microscopic polyarteritis, hypersensi-
PG

dependent Cushing’s syndrome, this can result

in Nelson’s syndrome, with an invasive pituitary tivity, or leukocytoclastic vasculitis): This type of necrotizing vas-
macroadenoma and very high ACTH levels causing culitis generally affects arterioles, capillaries, and venules—ves-
pigmentation. The risk of Nelson’s syndrome may be sels smaller than those involved in [Link] unusual cases larger
reduced by pituitary irradiation arteries may be involved. In contrast to PAN, all lesions tend to
be of the same age. It typically presents as “palpable purpura”
Cushing’s Disease: Management involving the skin, or involvement of the mucous membranes,
–– Harrison 19th/2272 lungs, brain, heart, gastrointestinal tract, kidneys, and muscle”
•• Selective transsphenoidal resection is the treatment of (Robbins 9th/510)
choice for Cushing’s disease “Wegener granulomatosis(Granulomatosis with polyangitis)
•• Biochemical recurrence occurs in approximately 5% of is a necrotizing vasculitis characterized by the triad of (1) acute
patients in whom surgery was initially successful. necrotizing granulomas of the upper respiratory tract (ear, nose,
•• When initial surgery is unsuccessful, repeat surgery is sinuses, throat), the lower respiratory tract (lung), or both;
sometimes indicated, particularly when a pituitary source (2) necrotizing or granulomatous vasculitis affecting small to
for ACTH is well documented. In older patients, in whom medium-sized vessels (e.g., capillaries, venules, arterioles, and
issues of growth and fertility are less important, hemi-
arteries), most prominent in the lungs and upper airways but
or total hypophysectomy may be necessary if a discrete
affecting other sites as well; and (3) renal disease in the form of
pituitary adenoma is not recognized.
focal necrotizing, often crescentic, glomerulitis” (Robbins 9th/511)
•• Pituitary irradiation may be used after unsuccessful
surgery, but it cures only about 15% of patients.. “Churg- Strauss syndrome(allergic granulomatosis and Answers

•• The use of steroidogenic inhibitors has decreased the need angiitis) is a multisystem diseases with cutaneous involvement &
Explanations
for bilateral adrenalectomy. (palpable purpura), gastrointestinal tract bleeding, and renal

553
 PGI Chandigarh Self-Assessment & Review: 2017–2013

disease (primarily as focal and segmental glomerulosclerosis)” Allopurinol, amphetamines, cocaine, thiazides, penicillamine,
(Robbins 9th/511) propylthiouracil, montelukast, TNF inhibitors, hepatitis B vaccine,
Eosinophilic granulomatosis with polyangiitis (Churg- trimethoprim/sulfamethoxazole
Strauss): It can occur in any organ in the body; lung
involvement is predominant, with skin, cardiovascular system, Table ( Harrison 19th/2154): Conditions Associated with Scleroderma-
kidney, peripheral nervous system,and gastrointestinal tract Like Induration
also commonly involved” (Harrison 17th/2186)
Chemically induced scleroderma-like conditions
112. Ans:  [Link]..., b. Pentazo..., c. Polyinyl.... Vinyl chloride–induced disease
[Ref: Neena Khanna 5th/ ; Harrison 19th/2154-55 ] Pentazocine-induced skin fibrosis
“Drug implicated in SSc-like illness includes bleomycin, Paraneoplastic syndrome
pentazocin & cocaine and appetite suppressant linked with
pulmonary hypertension” (Harrison 19th/2155)
“Occupational exposure tentatively linked with SSc include silica 113. Ans:  a. Biphasic..., b. Monophasic..., c. IV cannula...,
dust in miners, polyvinyl chloride, epoxy resins & aromatic d. After placing.....
hydrocarbons including toluene & trichloroethylene” (Harrison [Ref: [Link]; [Link]/]

/e
19th/2155)
“2010 AHA guideline for CPR (No change in 2015 Guideline):
Scleroderma is thickening of skin that is characteristically found
Contrary to previous recommendation of 3 successive shocks
in systemic sclerosis

,8
(200,300, 360 J) nowadays 1st & all subsequent shocks are of 360
Table (Harrison 19th/2218): Drug-Induced Musculoskeletal Condi- Joules with monophasic & 120-200 Joules with biphasic” (Ajay
tions Yadav 5th/ 259)

Scleroderma
Vinyl chloride, bleomycinQ, pentazocineQ, organic solvents,
carbidopa, tryptophan, rapeseed oil
a rh 2015 American Heart Association (AHA) Guidelines
Update for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiovascular Care (ECC)
ig
Defibrillation
Arthralgias At the advanced level, the cardiac arrest algorithm remains
nd

Quinidine, cimetidine, quinolones, chronic acyclovir, interferon, almost completely unchanged from the 2010 version.
IL-2, nicardipine, vaccines, rifabutin, aromatase and HIV protease Recommendations for defibrillation remain unchanged.
inhibitors Biphasic defibrillators are still preferred over monophasic
ha

Myalgias/myopathy devices. Single shocks are still preferred over multiple or stacked
shocks.
Glucocorticoids, penicillamine, hydroxychloroquine, AZT, lovastatin,
•• The AHA continues to recommend that EMS providers
iC

simvastatin, pravastatin, clofibrate, interferon, IL-2, alcohol, cocaine,

taxol, docetaxel, colchicine, quinolones, cyclosporine deliver the manufacturer’s recommended first energy dose.
If that dose is unknown, deliver the maximum energy dose
Tendon rupture allowed by the machine. It is also reasonable to follow the
PG

Quinolones, glucocorticoids defibrillator manufacturer’s recommendations on energy

Gout levels for subsequent defibrillation attempts
Diuretics, aspirin, cytotoxics, cyclosporine, alcohol, moonshine, Ventilation Rate
ethambutol •• After placing an advanced airway, the AHA continues to
recommend a ventilation rate of 10 breaths per minute
Drug-induced lupus
(one every six seconds) while providing continuous chest
HydralazineQ procainamideQ, quinidineQ, phenytoinQ, compressions.
carbemazepine, methyldopa, isoniazid, chlorpromazine, lithium,
Post-cardiac arrest care
penicillamine, tetracyclines, TNF inhibitors, ACE inhibitors,
ticlopidine •• With a few notable exceptions, changes to recommendations
Drug-induced subacute lupus for the post-cardiac arrest phase are minor, especially
Proton pump inhibitors, calcium channel blockers (diltiazem), ACE for those that could directly affect out-of-hospital care.
inhibitors, TNF inhibitors, terbinafine, interferons (α and β-1a), Once the patient achieves ROSC, one of the priorities
paclitaxel, docetaxel, HCTZ (Hydrochlorothiazide) highlighted in the 2010 guidelines was to optimize the
Osteonecrosis patient’s hemodynamic status. Although the 2010 cardiac
arrest algorithm lists a target of 90 mm Hg, the actual
Glucocorticoids, alcohol, radiation, bisphosphonates
recommendation at the time was to achieve a mean arterial
Osteopenia pressure (MAP) of at least 65 mm Hg.
Answers Glucocorticoids, chronic heparin, phenytoin, methotrexate •• In preparing for the 2015 guidelines, the research review
&
team could find no evidence of an optimal blood pressure
Explanations Vasculitis

554
 November  | 2015

target. Therefore, the AHA believes it is reasonable to avoid

and correct any hypotension (defined as a systolic blood
pressure less than 90 mm Hg or a MAP less than 65 mm
Hg) present during the post-resuscitation phase.

Summary of Key Issues and Major Changes

Key issues and major changes in the 2015 Guidelines Update
recommendations for advanced cardiac life support include
the following:
•• The combined use of vasopressin and epinephrine offers no
advantage to using standard-dose epinephrine in cardiac
arrest. Also, vasopressin does not offer an advantage over
the use of epinephrine alone. Therefore, to simplify the
algorithm, vasopressin has been removed from the Adult
Cardiac Arrest Algorithm–2015 Update.
•• Low end-tidal carbon dioxide (ETCO2) in intubated
patients after 20 minutes of CPR is associated with a very

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low likelihood of resuscitation. While this parameter should
not be used in isolation for decision making, providers

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may consider low ETCO2 after 20 minutes of CPR in
combination with other factors to help determine when to
terminate resuscitation.
•• Steroids may provide some benefit when bundled with
vasopressin and epinephrine in treating IHCA. While
routine use is not recommended pending follow-up studies,
it would be reasonable for a provider to administer the
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CPR Quality
Fig.: Adult cardiac arrest algorithm
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• Push hard (at least 2 inches [5 cm] and fast (100-120/min) and
bundle for IHCA. allow complete chest recoil.
nd

•• When rapidly implemented, ECPR can prolong viability, as • Minimize interruptions in compressions.
it may provide time to treat potentially reversible conditions • Avoid excessive ventilation.
or arrange for cardiac transplantation for patients who are • Rotate compressor every 2 minutes, or sooner if fatigued.
If no advanced airway, 30:2 compression-ventilation ratio.
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•
not resuscitated by conventional CPR.
• Quantitative waveform capnography
•• In cardiac arrest patients with nonshockable rhythm and ƒƒ If ETCO2 <10mm Hg, attempt to improve CPR quality
who are otherwise receiving epinephrine, the early provision • Intra arterial pressure.
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of epinephrine is suggested. ƒƒ If relaxation phase (diastolic) pressure <20 mm Hg, attempt to

•• Studies about the use of lidocaine after ROSC are improve CPR quality.
conflicting, and routine lidocaine use is not recommended. Shock Energy for Defibrillation
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However, the initiation or continuation of lidocaine may

• Biphasic: Manufacturer recommendation (e.g., initial dose of
be considered immediately after ROSC from VF/pulseless 120-200J); if unknown, use maximum available, Second and
ventricular tachycardia (pVT) cardiac arrest. subsequent doses should be equivalent, and higher closes may be
•• One observational study suggests that ß-blocker use after considered.
cardiac arrest may be associated with better outcomes than • Monophasic: 360 J
when ß-blockers are not used. Although this observational Drug Therapy
study is not strong-enough evidence to recommend routine
use, the initiation or continuation of an oral or intravenous • Epinephrine IV/lO dose: 1 mg every 3-5 minutes
• Amiodarone IV/lO dose: First dose: 300 mg bolus, Second dose:
(IV) ß-blocker may be considered early after hospitalization
150 mg.
from cardiac arrest due to VF/pVT.

Answers
&
Explanations

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•• Alternative but much less effective preventive agents

Advanced Airway
include chromones, leukotriene receptor antagonists, and
• Endotracheal intubation or supraglottic advanced airway theophyllines.
• Waveform capnography or capnometry to confirm and monitor
ET tube placement Step 3: Add-on therapy
• Once advanced airway in place, give 1 breath every 6 seconds (10 •• If a patient remains poorly controlled, despite regular use of
breaths/min) with continuous chest compressions ICS, a thorough review should be undertaken of adherence,
inhaler technique and ongoing exposure to modifiable
Return of Spontaneous Circulation (ROSC) aggravating factors.
• Pulse and blood pressure •• A further increase in the dose of ICS may benefit some
• Abrupt sustained increase in ETCO2 (typically > 40 mm Hg) patients but, in general, add-on therapy should be
• Spontaneous arterial pressure waves with intra-arterial considered in adults taking 800 μg/day BDP (or equivalent).
monitoring •• Long-acting β2-agonists (LABAs), such as salmeterol
and formoterol (duration of action of at least 12 hours),
Reversible Causes
represent the first choice of add-on therapy. They have
• Hypovolemia • Tension pneumothorax consistently been demonstrated to improve asthma control
• Hypoxia • Tamponade, cardiac and to reduce the frequency and severity of exacerbations
• Hydrogen ion (acidosis) • Toxins when compared to increasing the dose of ICS alone.

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• Hypo-/hyperkalemia • Thrombosis, pulmonary Fixed combination inhalers of ICS and LABAs have been
• Hypothermia • Thrombosis, coronary developed; these are more convenient, increase compliance

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and prevent patients using a LABA as monotherapy –
the latter may be accompanied by an increased risk of
114. Ans:  a. Continue inh..., b. Add inhaled..., c. Increase dose... life-threatening attacks or asthma death. The onset of

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[Ref: Davidson 22nd/669-71;Harrison 19th/1676-80; CMDT 06/231- action of formoterol is similar to that of salbutamol such
36;KDT 6th/226; Emergency Medicine-American College of Physician that, in carefully selected patients, a fixed combination of
6th/289] budesonide and formoterol may be used as both rescue
a
and maintenance therapy. Oral leukotriene receptor
The Stepwise Approach to the Management of Asthma
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antagonists (e.g. montelukast 10 mg daily) are generally less
–– Davidson 22nd/669-71 effective than LABA as add-on therapy, but may facilitate a
nd

Step 1: Occasional use of inhaled short-acting β2-adreno- reduction in the dose of ICS and control exacerbations. Oral
receptor agonist bronchodilators theophyllines may be considered in some patients but their
•• For patients with mild intermittent asthma (symptoms less unpredictable metabolism, propensity for drug interactions
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than once a week for 3 months and fewer than two nocturnal and prominent side-effects limit their widespread use.
episodes per month), it is usually sufficient to prescribe an Step 4: Poor control on moderate dose of inhaled steroid and
inhaled short-acting β2-agonist, such as salbutamol or add-on therapy: addition of a fourth drug
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terbutaline, to be used as required. •• In adults, the dose of ICS may be increased to 2000 μg
•• A history of a severe exacerbation should lead to a step-up BDP/BUD (or equivalent) daily. A nasal corticosteroid
in treatment. preparation should be used in patients with prominent
PG

•• The metered-dose inhaler remains the most widely pre- upper airway symptoms. Oral therapy with leukotriene
scribed inhaled devices receptor antagonists, theophyllines or a slow-release β2-
Step 2: Introduction of regular preventer therapy agonist may be considered. If the trial of add-on therapy is
•• Regular anti-inflammatory therapy (preferably inhaled ineffective, it should be discontinued. Oral itraconazole may
corticosteroids (ICS), such as beclometasone, budesonide be contemplated in patients with allergic bronchopulmonary
(BUD), fluticasone or ciclesonide) should be started in aspergillosis
addition to inhaled β2-agonists taken on an as-required Step 5: Continuous or frequent use of oral steroids
basis for any patient who: •• At this stage, prednisolone therapy (usually administered
 Has experienced an exacerbation of asthma in the last 2 as a single daily dose in the morning) should be prescribed
years in the lowest amount necessary to control symptoms.
 Uses inhaled β2-agonists three times a week or more Patients on long-term corticosteroid tablets (> 3 months) or
 Reports symptoms three times a week or more receiving more than three or four courses per year will be at
 Is awakened by asthma one night per week. risk of systemic side-effects

Answers
&
Explanations

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 November  | 2015

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nd
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Fig.: (Davidson 22nd/670): Stepwise approach for asthma

Answers
&
Fig.: (Harrison 19th/1679): Stepwise approach to asthma therapy according to the severity of asthma and ability to control symptoms. ICS, inhaled Explanations
corticosteroids; LABA, long-acting β2-agonist; OCS, oral corticosteroid.

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 PGI Chandigarh Self-Assessment & Review: 2017–2013

“MDI (Metered dose inhaler) deliver a specified dose of the drug in spray form per actuation. A spacer (chamber imposed b/w the
inhaler & the patients mouth) can be used to improve drug delivery. Nebulizers produces a mist of drug solution generated by pressurized
air or oxygen which can be inhaled through mouth piece, face mask or in a tent” (KDT 6th/226)
Inhaled steroids are used in two form: (KDT 6th/226)
•• Use drug in solution: metered dose inhaler, nebulizer
•• Use drug as dry powder: spinhaler, rotahaler
“Inhaled Corticosteroids (ICSs) are by far the most effective controllers for asthma, and their early use has revolutionized asthma
therapy”(Harrison 18th/ 2111)

115. Ans:  a. Asymptomatic...., b. Persistent generalised....

[Ref: Harrison 19th/ 1215-25; Davidson 22nd/394; Park 23rd/349]

Natural History & Clinical Staging of HIV

–– Davidson 22nd/394
•• Clinical staging of patients should be done at the initial medical examination, as it provides prognostic information and is a key
criterion for initiating ART and prophylaxis against opportunistic infections. Two clinical staging systems are used internationally
are- WHO system & CDC system

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•• In both systems, patients are staged according to the most severe manifestation and do not improve their classification. For example,
a patient who is asymptomatic following a major opportunistic disease (AIDS) remains at stage 4 or category C of the WHO and

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CDC systems respectively, and never reverts to earlier stages.
•• Finally, patients do not always progress steadily through all stages and may present with AIDS, having previously been asymptomatic.

Table (Davidson 22nd/394) : HIV Clinical Staging Classifications

World Health Organization (WHO) clinical stage {used in low- and

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Centers for Disease Control (CDC) clinical categories (used in high-
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middle-income countries} income countries)
Stage 1 Category A
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Asymptomatic Primary HIV infection

Persistent generalised lymphadenopathy Asymptomatic
Persistent generalised lymphadenopathy
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Stage 2 Category B
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Unexplained moderate weight loss (< 10% of body weight) Bacillary angiomatosis
Recurrent upper respiratory tract infections Candidiasis, oropharyngeal (thrush)
Herpes zoster Candidiasis, vulvovaginal; persistent, frequent or poorly responsive to
PG

Angular cheilitis therapy

Recurrent oral ulceration Cervical dysplasia (moderate or severe) /cervical carcinoma in situ
Papular pruritic eruptions Constitutional symptoms, such as fever (38.5°C) or diarrhoea lasting.> 1
Seborrhoeic dermatitis mth
Fungal nail infections Oral hairy leucoplakia
Herpes zoster, involving two distinct episodes or more than one
Stage 3 dermatome
Unexplained severe weight loss (> 10% of body weight) Idiopathic thrombocytopenic purpura
Unexplained chronic diarrhoea for > 1 mth Listeriosis
Unexplained persistent fever (> 37.5°C for > 1 mth) Pelvic inflammatory, disease, particularly if complicated by tubo-ovarian
Persistent oral candidiasis abscess
Oral hairy leucoplakia Peripheral neuropathy
Pulmonary tuberculosis
Severe bacterial infections
Acute necrotising ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (< 80 g/L (8 g/L)), neutropenia (< 0.5 × 109/L)
and/or chronic thrombocytopenia (< 50 × 109/L

Answers
&
Explanations

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 November  | 2015

Stage 4 Category C
Candidiasis of oesophagus, trachea, bronchi or lungs
Cervical carcinoma - invasive
Cryptococcosis - exlrapulmonary
Cryptosporilosis, chronic (> 1 mth) Cytomegalovirus disease (outside liver, spleen and nodes)
Herpes simplex chronic (> 1 mth) ulcers or visceral
HIV encephalopathy
HIV wasting syndrome
Isosporiasis, chronic (> 1 mth)
Kaposi's sarcoma
Lymphoma (cerebral or B-cell non-Hodgkin)
Mycobacterial infection, non-tuberculous, extrapulmonary or disseminated
Mycosis - disseminated endemic (coccidiodomycosis or histoplasmosis)
Pneumocystis pneumonia
Pneumonia, recurrent bacterial
Progressive multioflocal leucoencephalopathy
Toxoplasmosis – cerebral
Tuberculosis - extrapulmonary (CDC includes pulmonary)

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Septicaemia, recurrent (including non-typhoidal Salmonella) (CDC only includes Salmonella)
Symptomatic HIV-associated nephrepathy*

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Symptomatic HIV-associated cardiomyopathy*
Leishmoniasis, atypical disseminated*
These conditions are in WHO stage 4 but not in CDC category C.
*

WHO Clinical Staging System for HIV Infection and HIV

Related Disease
–– Park 23rd/349
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Unexplained persistent fever (intermittent or constant for longer
than 1 month)
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Persistent oral candidiasis
•• WHO has developed a clinical staging system based on clin-
ical criteria Oral hairy leukoplakia
nd

•• Clinical condition or performance score, which is the high- Pulmonary tuberculosis

er, determines whether a patient is at clinical stage 1, 2, 3
or 4 Severe bacterial infections (e.g. Pneumonia, Empyema, meningitis,
ha

•• Clinical stage is important as a criteria for starting antiret- pyomyositis, bone or joint infection bacteraemia, Severe pelvic
roviral therapy (ART) inflammatory disease)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Table (Park 23rd/349): WHO HIV Staging
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Unexplained anaemia (below 8 g/dl), neutropenia

Clinical Stage 1 (below 0.5 ×109/1 and/or chronic thrombocytopenia
Asymptomatic (below 50×109/1)
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Persistent generalized lymphadenopathy Clinical Stage 4

Clinical Stage 2 HIV wasting syndrome

Moderate unexplained weight loss (under 10% of presumed or Pneumocystis jiroveci pneumonia
measured body weight) Recurrent severe bacterial pneumonia
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis Chronic herpes simplex infection (orolabial, genital or anorectal
media, pharyngitis) of more than 1 month’s duration or visceral at any site)
Herpes zoster Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Angular cheilitis Extrapulmonary tuberculosis
Recurrent oral ulcerations Kaposi sarcoma
Papular pruritic eruptions Cytomegalovirus disease (retinitis or infection of other organs,
Seborrhoeic dermatitis excluding liver, spleen and lymph nodes)

Fungal nail infections Central nervous system toxoplasmosis

HIV encephalopathy”
Clinical Stage 3
Extrapulmonary cryptococcosis including meningitis
Unexplained severe weight loss (over 10% of presumed or measured
Answers
body weight) Disseminated non-tuberculous mycobacteria infection &
Explanations
Unexplained chronic diarrhea for longer than 1 month Progressive multifocal leukoencephalopathy

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SURGERY •• DCIS makes up less than 15% of male breast cancer, while
infiltrating NST makes up more than 85%. Special-type
cancers, including infiltrating lobular carcinoma, have
116. Ans:  d. Spinal cord injury without.... occasionally been reported.
[Ref: Sabiston 19th / 441] •• Male breast cancer is staged in an identical fashion to
female breast cancer, and, stage by stage, men with breast
“Vertebral & spinal cord injury in trauma patient: A small group cancer have the same survival rate as women.
of patients will have spinal cord injury without radiographic •• Overall, men do worse because of the advanced stage of
abnormality (SCIWORA). Originally described in pediatric their cancer (stage III or IV) at the time of diagnosis.
patients, SCIWORA is now seen more frequently in adults. •• The treatment of male breast cancer is surgical, with
The use of magnetic resonance imaging (MRI) in these patients the most common procedure being a modified radical
will reveal the cause of the injury in many patients”-Sabiston mastectomy. Adjuvant radiation therapy is appropriate in
19th/441 cases where there is a high risk for local recurrence.
“The acronym SCIWORA (Spinal Cord Injury Without •• Eighty percent of male breast cancers are hormone receptor–
Radiographic Abnormality) was first developed and positive, and adjuvant tamoxifen is considered.
introduced by Pang and Wilberger who used it to define “clinical •• Systemic chemotherapy is considered for men with
symptoms of traumatic myelopathy with no radiographic hormone receptor–negative cancers and for men with large
or computed tomographic features of spinal fracture or primary tumours, positive nodes & locally advanced disease

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instability”. SCIWORA is a clinical-radiological condition that
mostly affects children. SCIWORA lesions are found mainly 118. Ans:  b. Radiosen....

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in the cervical spine but can also be seen, although much
less frequently, in the thoracic or lumbar spine.. With recent [Ref: L & B 26th/768-69; Sabiston 19th/1005-06 ]
advances in neuroimaging techniques, especially in magnetic
Medullary Carcinoma

rh
resonance imaging, and with increasing availability of MRI as
a diagnostic tool, the overall detection rate of SCIWORA has –– Sabiston 19th/1005-06
significantly improved” •• MCT accounts for 3% to 9% of thyroid cancers & arises from
a
parafollicular cell, or C cell, derived from the neural crest.
ig
117. Ans:  c. Staging is different... •• MCT is associated with the secretion of a biologic marker,
calcitonin. Excess secretion of calcitonin has been
[Ref: L & B 26th/819; Manipal Surgery 4th/419;Schwartz 9th/468]
nd

demonstrated to be an effective marker for the presence of

“Male breast cancers tends to more advanced at time of MCT. Calcitonin excess is not associated with hypocalcemia.
presentation because of less subcutaneous fat” (Manipal Surgery •• Medullary carcinoma can occur in a sporadic form or as part
ha

4th/419) of MEN 2A or 2B. MEN 2A usually has a more favorable

Carcinoma of the Male Breast long-term outcome than MEN 2B or sporadic MCT does
•• In sporadic MCT, the tumors are usually single and have
–– L & B 26th/819
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no familial predisposition. The presence of both a mass

•• Carcinoma of the male breast accounts for less than 0.5 per
and an elevated calcitonin level is virtually diagnostic of
cent of all cases of breast cancer. The known predisposing
MCT, whereas the finding of an elevated basal calcitonin
causes include gynaecomastia and excess endogenous or level in the absence of a thyroid mass might require further
PG

exogenous oestrogen. workup, including repeat basal calcitonin measurement and

•• As in the female, it tends to present as a lump and is most
a calcium-stimulated or gastrin-stimulated test.
commonly an infiltrating ductal carcinoma. •• If MCT is suspected, serum calcium and urinary
•• Stage for stage the treatment is the same as for carcinoma catecholamines must be determined to evaluate for
in the female breast and prognosis depends upon stage at hyperparathyroidism and possible pheochromocytoma.
presentation. •• Recommended surgical treatment of MTC is influenced by
•• Adequate local excision, because of the small size of the several factors. First, the clinical course of MTC is usually
breast, should always be with a ‘mastectomy’. more aggressive than that of differentiated thyroid cancer,
Male Breast Cancer with higher recurrence and mortality rates. Second, MTC
–– Schwartz 9th/468 cells do not take up radioactive iodine, and radiation
•• Less than 1% of all breast cancers occur in men. Male breast therapy and chemotherapy are ineffective. Third, MTC
cancer is preceded by gynecomastia in 20% of men. is multicentric in 90% of patients with the hereditary
•• It is associated with radiation exposure, estrogen therapy, forms of the disease. Fourth, in patients with palpable
testicular feminizing syndromes, and with Klinefelter’s disease, more than 70% have nodal metastases. Lastly,
syndrome (XXY). the ability to measure postoperative stimulated calcitonin
•• Breast cancer is rarely seen in young males and has a peak
levels has allowed assessment of the adequacy of surgical
extirpation. Screening for pheochromocytoma is done
incidence in the sixth decade of life.
before performing thyroid surgery. If patients are found to
Answers •• A firm, nontender mass in the male breast requires
& have evidence of pheochromocytoma, adrenal surgery with
Explanations investigation. Skin or chest wall fixation is particularly
perioperative α-blockade precedes other procedures
worrisome.

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 November  | 2015

Medullary Carcinoma •• There is no definitive surgical solution to the problem except

–– L & B 26th/768-69 in rare cases with isolated involvement of one hepatic lobe,
•• These are tumours of the parafollicular (C cells) derived where lobectomy is curative. Intermittent antibiotic therapy
from the neural crest and not from the cells of the thyroid for cholangitis is the usual regimen.
follicle as are other primary thyroid carcinomas. Caroli’s Disease
•• The cells are not unlike those of a carcinoid tumour and –– L & B 26th/ 1105-06
there is a characteristic amyloid stroma. High levels •• This is congenital dilatation of the intrahepatic biliary tree,
of serum calcitonin and carcinoembryonic antigen are which is often complicated by the presence of intrahepatic
produced by many medullary tumours. stone formation. Presentation may be with abdominal pain
•• Calcitonin levels fall after resection and rise again with or sepsis.
recurrence making it a valuable tumour marker in the •• Imaging is usually diagnostic, with the finding on
follow up of patients with this disease. ultrasound or CT of intrahepatic biliary lakes containing
•• Diarrhoea is a feature in 30 per cent of cases and this may be stones. Biliary stasis and stone formation combine to
due to 5-hydroxytryptamine or prostaglandins produced predispose to biliary sepsis, which may be life-threatening.
by the tumour cells. •• Another well-recognised complication is the development
•• Involvement of lymph nodes occurs in 50–60 per cent of of carcinoma.
cases of medullary carcinoma and blood-borne metastases No specific treatment is available. Acute infective episodes

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••
are common. As would be expected, tumours are not TSH are treated with antibiotics.
dependent and do not take up radioactive iodine. •• Obstructed and septic bile ducts may be drained either

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radiologically or surgically. Malignant change within the
119. Ans:  a. Intrahepatic..., b. Jaundice..., c. ↑ Serum...
ductal system results in cholangiocarcinoma, which may be
e. Surgery...
amenable to resection.
[Ref: L & B 26th/ 1105-06; Sabiston 19th/1465;Manipal Surgery
4th/582;Schwartz 9th/1119,1440;CSDT 11th/621]
“Caroli’s disease: Approx. 33% of affected patients develop
a rh •• Segmental involvement of the liver by Caroli’s disease may
be treated by resection of the affected part, although the
ductal dilatation is usually diffuse. Liver transplantation is
ig
biliary lithiasis & 7% develop cholangiocarcinoma. Rarely, a radical but definitive treatment.
patients can present later in life with complication secondary Caroli’s Disease (Type V Choledochal Cyst)
nd

to portal hypertension. If disease is limited to a single lobe of –– Sabiston 19th/1465

liver, hepatic resection can be beneficial. Liver resection can •• Caroli’s disease is multifocal dilation of the segmental bile
be considered in the patients with hepatic decompensation or ducts that are separated by portions of normal-caliber bile
ha

unresponsive recurrent cholangitis possibly in the patient with a ducts.

small T1 or T2 cholangiocarcinoma” (Schwartz 9th/1119) •• When intrahepatic bile duct cysts are localized, hepatic
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resection with or without biliary reconstruction is the

Caroli’s Disease
treatment of choice.
–– CSDT 11th/621 •• Treatment of diffuse hepatic involvement is poor, and
•• It consists of saccular intrahepatic dilatation of the ducts. In probably the only effective treatment is transplantation in
PG

some cases, the biliary abnormality is an isolated finding, complicated cases

but more often it is associated with congenital hepatic
fibrosis and medullary sponge kidney. 120. Ans:  a. Left gastric..., e. Occur at lower....
•• The latter patients often present in childhood or as young
[Ref: L & B 26th/ 1074-75; Manipal Surgery 4th/538; Harrison 19th/277]
adults with complications of portal hypertension. Others
have cholangitis and obstructive jaundice(So increased “The pharynx extends from the base of the skull down to the
alkaline phosphatase) as initial manifestations. inferior border of the cricoid cartilage (around the C6 vertebral
level), where it becomes continuous with the esophagus”

Answers
&
Explanations

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a rh
Fig.: (Manipal Surgery 4th/538): Collaterals

Table (Manipal Surgery 4th/538): Anastomosis b/w the portal & systemic venous system
ig
Site Portal vessels Systemic vessels Effect
1. Lower end of oesophagus Branches of left gastric vein and short Branches from azygos vein Oesophageal varices
nd

gastric vein
2. Falciform ligament of liver Veins which run in the falciform ligament Anterior abdominal wall Caput medusa*
ha

(paraumbilical vein) veins

3. Lower end of rectum Superior haemorrhoidal vein Inferior and middle Piles (very rare), rectal varices
haemorrhoidal vein
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4. Retroperitoneum mesenteric Branches of superior and inferior Retroperitoneal veins Retroperitoneal varices (silent)
veins subdiaphragmatic veins
*Most often, veins which run in the falciform ligament are obliterated from birth. Hence, it is not commonly seen.
PG

Table (B.D.C 6th/[Link] 285): Sites of portocaval/portosystemic anastomoses

Portal vein Systemic vein

Lower end of esophagus Left gastric Oesophageal veins

121. Ans:  a. Better tole..., c. Diarrhea..., d. High recurr..., e. Operative....

[Ref: L & B 26th/1036-38; Manipal Surgery 4th/473; Schwartz 9th/914-15]

Highly selective vagotomy (Also called parietal cell vagotomy)

–– Manipal Surgery 4th/473
•• In this, vagi are not divided at the trunk. The branch of nerves of Latarjet supplying parietal cell mass are divided.
•• Advantage
More physiological, with minimal disturbances
No drainage procedure is required because pyloric functions are preserved
 Nerve supply to gall bladder & liver is not disturbed
 No diarrhea as that can occur in 5-8% of cases of truncal vagotomy which can be morbid
Answers
& •• Disadvantage
Explanations  This is not the procedure for prepyloric ulcer as there is a high recurrence rate

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 November  | 2015

 Complicated procedure- needs an experienced surgeon •• When applied to uncomplicated duodenal ulcer, the
 Recurrence rate: 10-15% recurrence rate is higher with HSV than with vagotomy
 Rare chance of lesser curvature necrosis and antrectomy.
•• HSV has not performed particularly well as a treatment for
Table ( Schwartz 9th/915): Clinical Results of Surgery for Duodenal
type II (gastric and duodenal) and III (prepyloric) gastric
Ulcer
ulcer, perhaps because of hypergastrinemia caused by
Parietal Truncal Truncal gastric outlet obstruction and persistent antral stasis.
Cell Vagotomy and Vagotomy and Highly Selective Vagotomy
Vagotomy Pyloroplasty Antrectomy –– L & B 26th/1037
Operative 0 <1 1 •• In this only the parietal cell mass of the stomach was
mortality rate denervated. This proved to be the most satisfactory
(%) operation for duodenal ulceration, with a low incidence
Ulcer 5–15 5–15 <2 of side-effects and acceptable recurrence rates when
recurrence performed to a high technical standard.
rate (%) •• The operative mortality rate was lower than any other
Dumping (%) definitive operation for duodenal ulceration, in all

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probability because the gastrointestinal tract was not
Mild <5 10 10–15
opened during this procedure.
Severe 0 1 1–2 •• The unpleasant effects of surgery were largely avoided,

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Diarrhea (%) although loss of receptive relaxation of the stomach did
occur, leading to epigastric fullness and sometimes mild
Mild <5 25 20
dumping. However, the severe symptoms that are seen after
Severe 0 2 1–2

Table ( L & B 26th/1037): Operative mortality, side effects and

a rh other more destructive gastric operations did not occur.
•• It is often said that recurrent ulceration was the Achilles heel
of this operation although, when performed well, recurrence
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incidence of recurrence following duodenal ulcer operations was no more common than after truncal vagotomy. The
operation disappeared from routine use with the advent of
Operation Operative Significant Recurrent
nd

mortality (%) side- ulceration anti-secretory agents and eradication therapy.

effects (%) (%) Truncal Vagotomy and Drainage
ha

Gastrectomy 1–2 20–40 1–4 –– L & B 26th/1036-38

Gastroenterostomy <1 10–20 50 •• The principle of the operation is that section of the vagus
alone nerves, which are critically involved in the secretion of gastric
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acid, reduces the maximal acid output by approximately 50

Truncal vagotomy <1 10–20 2–7
and drainage
per cent. Because the vagal nerves are motor to the stomach,
denervation of the antropyloroduodenal segment results in
Selective vagotomy <1 10–20 5–10 gastric stasis in a sub- stantial proportion of patients on
PG

and drainage whom truncal vagotomy alone is performed. The most

Highly selective <0.2 <5 2–10 popular drainage procedure is the Heineke– Mikulicz
vagotomy pyloroplasty
Truncal vagotomy 1 10–20 1 •• The operation of truncal vagotomy and drainage is
and antrectomy substantially safer than gastrectomy However, the side
effects of surgery are, in fact, little different from those that
Highly Selective Vagotomy follow gastrectomy.
–– Schwartz 9th/914-15
•• Highly selective vagotomy (HSV), also called parietal cell 122. Ans:  a. Superior..., b. Gland can..., c. The presence...,
vagotomy or proximal gastric vagotomy, is safe (mortality d. Intraoperative...
risk <0.5%) and causes minimal side effects.
[Ref: L & B 26th/774; Sabiston 19th/925-934;Nelon 20th/2691;Schwartz
•• It preserves the vagal innervation to the antrum and pylorus,
9th/1381-83;CSDT 11th/307-08;Manipal Surgery 4th/363-64]
and the remaining abdominal viscera.
•• HSV decreases total gastric acid secretion by about 65 to “There are usually four parathyroid glands, which lie on the
75%, which is quite comparable to the reduction seen with posterior surface of the thyroid. Common sites for ectopic
truncal vagotomy and acid-suppressive medication. Gastric parathyroids are the thyrothymic ligament, superior thyroid
emptying of solids is typically normal in patients after poles, tracheoesophageal groove, retroesophageal space,
parietal cell vagotomy; liquid emptying may be normal or and carotid [Link] percentage of individuals with
Answers
increased due to decreased compliance associated with loss supernumerary glands varies in published series from 2.5% to &
of receptive relaxation and accommodation. 22%” (Sabiston 19th/925) Explanations

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 PGI Chandigarh Self-Assessment & Review: 2017–2013

Anatomy of Parathyroid Gland •• Most adults have four parathyroid glands but supernumerary
–– CSDT 11th/307-08 glands occur and nests of parathyroid tissue are commonly
•• Four parathyroid glands are present in 85% of the found in the thymus.
population, and about 15% have more than four glands. Operation for Primary Hyperparathyroidism
Occasionally, one or more may be incorporated into the –– L & B 26th/774
thyroid gland or thymus and hence are intrathyroidal or •• A gamma probe can be used to guide exploration following
mediastinal in location preoperative injection of technetium-labelled sestamibi.
•• The normal parathyroid gland has a distinct yellowish- The short serum half-life of PTH means that intraoperative
brown color, is ovoid, tongue-shaped, polypoid, or spherical, measurement can be used to confirm that the source of
and averages 2 × 3 × 7 mm. excess PTH production has been excised. This is a more
physiological approach than surgical opinion supported
Primary Hyperparathyroidism: Operation by frozen section and is routine in many centres but is not
•• CSDT 11th/313 infallible or inexpensive.
•• At operation, a normal and abnormal parathyroid should •• Serum levels of PTH are measured pre-incision, pre-
be identified on the side of the localized tumor. A focal removal, 5 minutes after removal and 10 minutes after
operation can be done in similar patients and the operation removal. The assay takes 30 minutes and if the percentage
completed when the intraoperative PTH level decreases drop is not >50 per cent then further exploration is
by more than 50% from the highest pre-removed value 10

/e
indicated.
minutes after the parathyroid tumor is removed.
•• In over 80% of cases, the parathyroid tumor is found 123. Ans:  a. Pneumone..., b. Lung..., c. Hemothorax...,

,8
attached to the posterior capsule of the thyroid gland. The e. Diagnosis....
parathyroid glands are usually symmetrically placed, and [Ref: L & B 26th/857;CSDT 11th /245;Schwartz 9th/364,562,537,1423]
lower parathyroid glands are situated anterior to the
recurrent laryngeal nerve, whereas the upper parathyroid
glands lie posterior to the recurrent laryngeal nerve
•• Care must be taken to avoid bleeding and not to traumatize
a rh “Throracoscopy: Used for esophageal & tracheoesophageal
fistula repair (Schwartz 9th/1423)
“Thoracoscopy or video-assisted thoracoscopic surgery:
Pneumonectomy, lobectomy and empyema drainage are all
ig
the parathyroid gland or tumors, since color is useful in
distinguishing them from surrounding thyroid, thymus, possible. However, lung biopsy and the treatment of recurrent
pneumothorax are the most frequent indications. The principal
nd

lymph node, and fat.

•• One should attempt to identify four parathyroid glands
advantage is that a large incision is avoided resulting in less
when a bilateral approach is elected, though there may be postoperative pain and a more rapid recovery” (L & B 26th/857)
ha

more than four or fewer than four. “Hemothorax: Tube thoracostomy should be performed
•• If a probable parathyroid adenoma is found, it is removed
expeditiously for all hemo- or pneumothoraces. In 85% of cases,
and the diagnosis confirmed by frozen section or by a tube thoracostomy is the only treatment required. If bleeding is
iC

greater than 50% decrease in PTH. persistent, as noted by continued output from the chest tubes,
•• The presence of a normal parathyroid gland at operation
it is more likely to be from a systemic (e.g., intercostal) rather
indicates that the tumor removed is an adenoma rather than a pulmonary artery. When the rate of bleeding shows a
PG

than parathyroid hyperplasia, since in hyperplasia all steady trend of greater than 200 mL/h or the total hemorrhagic
the parathyroid glands are involved. A compressed rim of output exceeds 1500 mL, thoracoscopy or thoracotomy should
normal parathyroid tissue is also suggestive of an adenoma. usually be performed. The trend and rate of thoracic bleeding
•• When all parathyroid glands are hyperplastic, the most
is probably more important than the absolute numbers in
normal gland should be subtotally resected, leaving a 50 mg deciding to perform surgical intervention. Thoracoscopy has
remnant, and confirmed histologically before removal of the been shown to be effective in controlling chest tube bleeding in
remaining glands. The upper thymus and perithymic tract 82% of cases. This technique has also been shown to be 90%
should be removed in patients with hyperplasia, because a effective in evacuating retained hemothoraces. In most of these
fifth parathyroid gland is present in 15% of cases. cases, the chest wall is the source of hemorrhage. Thoracotomy
•• The recurrence rate of hyperparathyroidism after the
is required for management of injuries to the lungs, heart,
removal of a single adenoma in patients with sporadic pericardium, and great vessels” (CSDT 11th /245)
hyperparathyroidism is 2% or less. Video-Assisted Thoracoscopic Surgery (VATS)
•• Following removal of a parathyroid adenoma or hyperplastic –– CSDT 11th/350
glands, the serum calcium concentration falls to normal or •• VATS plays an important role in the diagnosis and staging
below normal in 24–48 hours. of thoracic malignancies (lung cancer, mesothelioma, etc)
Parathyroid Gland as well as in the resection of isolated peripheral pulmonary
–– L & B 26th/774
nodules and bullous lung disease. Furthermore, it has been
•• The normal parathyroid gland weighs up to 50 mg with a
an advance in lung biopsy and pleurodesis procedures.
Answers
•• However, despite gaining popularity, many thoracic surgeons
&
characteristic orange/brown colour and mobility within
Explanations
the surrounding fat and thymic tissue. consider the approach suboptimal for lung cancers.

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