Practise NEET PG MCQs. Revise with focus.

Answer: D. Vagal trunk

The vagal trunk does not pass through the aortic opening of the diaphragm. It passes through the esophageal opening at the level of T10 vertebra.

Answer: A. Keratinised epithelium, submucosa, minor salivary glands

The hard palate contains keratinised stratified squamous epithelium, has a submucosa, andcontains minor salivary gland. This keratinised stratified squamous epithelium has regionalvariations and may be orthokeratinised or parakeratinised(found in hard palate and gingiva). The bony structure of the hard palate is covered by a firmly attached mucosa in the central part.In the lateral parts, the hard palate also has a submucosal layer containing blood vessels. Thereare minor mucous type salivary glands in the submucosa in the posterior part of the hard palate. (Note: In the orthokeratinized epithelium the cell nuclei disappear in the keratinized layer,whereas in the parakeratinized epithelium flattened, highly condensed nuclei remain in the cellcytoplasm of the keratinized layer until exfoliation)

Answer: B. Physiological hernia failing to go back

Omphalocele is protrusion of abdominal contents through the umbilical ring. It is due to failure ofphysiological hernia to reduce into the abdominal cavity, which results in non-closure of theumbilical ring. . An omphalocele may contain stomach, liver, and intestines. And these contents are enclosed in asac. Omphalocele is usually associated with other congenital anomalies (e.g., trisomy 13, trisomy 18, orBeckwith-Wiedemann syndrome) and with increased levels of α-fetoprotein. Note: In gastroschisis, there is an absence of a membranous sac and is paraumbilical.

Answer: D. Superior cerebellar

Thrombosis of the superior cerebellar artery causes cerebellar lesion which presents with ataxiaand incoordination. Blood supply of cerebellum: • Superior cerebellar artery • Posterior inferior cerebellar artery • Anterior inferior cerebellar artery

Answer: A. Lateral pterygoid

The muscle that is attached to the articular disc of the temporomandibular joint is the lateralpterygoid. Lateral pterygoid muscle: • Origin - Upper head arises from the infratemporal surface and infratemporal crest of the greaterwing of the sphenoid bone. The lower head arises from the lateral surface of the lateral pterygoidplate. • Insertion - It is inserted into the pterygoid fovea, the capsule of the temporomandibular joint,and the articular disc. The action of lateral pterygoid muscle is depression, protrusion, and side-to-side movement of thejaw.

Answer: B. Posterior tibial artery

The posterior tibial artery, located behind the medial malleolus and 2.5 cm in front of thetendocalcaneus, that is used for arteriovenous (AV) shunting with the great saphenous vein forhemodialysis. The posterior tibial artery is situated behind the medial malleolus and approximately 2.5 cm infront of the tendocalcaneus, making it a suitable site for creating an AV fistula with the greatsaphenous vein. This location allows for optimal access and ensures that the shunt can handle thenecessary blood flow for effective dialysis with the great saphenous vein. However, they are notcommonly used for AV shunting in common practices. Arteries used for AV shunting include the radial artery and the brachial artery in the upper arm,which are frequently employed for hemodialysis access. In the lower leg, the anterior tibial arteryand the peroneal (fibular) artery are less commonly used for this procedure. Other options: Option A: In comparison, the anterior tibial artery is located on the anterior aspect of the leg andruns down the front of the tibia, not behind the medial malleolus. Option C: The peroneal (fibular) artery is situated on the lateral side of the leg, travellingalongside the fibula, and is also not located behind the medial malleolus. Option D: The fibular circumflex artery is a small artery and is not commonly used forhemodialysis access. It is not a standard choice and does not fit the anatomical location described,as it is a branch of the anterior tibial artery.

Answer: B. Competitively blocking the binding of ACh to its receptors

The curare group of drugs includes non-depolarizing neuromuscular blocking agents that act bycompetitively blocking the binding of acetylcholine to its receptors. This leads to a decrease in the effect of acetylcholine and thus, neuronal transmission to themuscle does not occur.

Answer: D. Endotracheal tube

Murphy's eye is seen in the endotracheal tube (ETT). Murphy's eye refers to the distal opening in the side wall of the ETT. If the distal end of the lumen of the tube is blocked by secretions, Murphy's eye serves to providean alternate route for ventilation.

Answer: B. Competitively blocking the binding of ACh to its receptors

The curare group of drugs includes non-depolarizing neuromuscular blocking agents that act bycompetitively blocking the binding of acetylcholine to its receptors. This leads to a decrease in the effect of acetylcholine and thus, neuronal transmission to themuscle does not occur.

Answer: A. Etomidate

Etomidate, a short-acting I.V. anesthetic agent doesn’t cause myocardial depression. Etomidate is the most cardiac stable intravenous agent due to its lack of effect on the sympatheticnervous system and on the function of the baroreceptor. Hence, etomidate is the I.V. agent ofchoice in patients with coronary artery disease, cardiomyopathy, and cerebral vascular disease. Side effects of Etomidate: • The highest incidence of nausea and vomiting among inducing agents • Superficial thrombophlebitis and pain on injection • Adrenocortical suppression Note: Although Ketamine has an indirect sympathetic stimulatory effect, it possesses a directnegative inotropic effect on the myocardium. Hence, ketamine has to be used cautiously incritically ill patients with shock, as they are prone to have a depletion of endogenouscatecholamines. Ketamine infusion in such patients can unmask its direct negative inotropiceffects and further decrease the blood pressure and cardiac output. Hence, for this MCQ, Etomidate is the best answer.

Answer: D. Cefazolin

First- and second-generation cephalosporins (cefazolin) are the drugs of choice for preoperativeprophylaxis for cardiac surgery. Clindamycin is reserved for cases of allergy to beta-lactams andvancomycin is recommended for methicillin-resistant Staphylococcus aureus (MRSA). Preoperative antibiotic prophylaxis is essential in reducing the risk of surgical site infections,particularly in cardiac surgery, where the consequences of infection can be severe. The choice ofantibiotic depends on the patient's medical history, allergies, and the most common pathogensinvolved in surgical site infections for the specific surgery. In addition to cefazolin, othercephalosporins, such as cefuroxime, can also be used for prophylaxis in cardiac surgery. Thetiming of antibiotic administration is crucial, with the first dose typically given within 60 minutesbefore the incision. Other Options: Option A: Penicillin G is not the drug of choice for preoperative antibiotic prophylaxis in cardiacsurgery. It is mainly used to treat infections caused by susceptible gram-positive bacteria, such asStreptococcus pyogenes, Streptococcus pneumoniae, and some strains of Staphylococcus aureus. Option B: Erythromycin is a macrolide antibiotic and is not the drug of choice for preoperativeprophylaxis in cardiac surgery. It is typically used to treat respiratory tract infections, skininfections, and other infections caused by susceptible gram-positive bacteria. Option C: Azithromycin, another macrolide antibiotic, is also not the drug of choice forpreoperative prophylaxis in cardiac surgery. It is commonly used to treat respiratory tractinfections, sexually transmitted infections, and other infections caused by susceptiblegram-positive and gram-negative bacteria.

Answer: C. Sugammadex

Sugammadex is used for immediate reversal of vecuronium-induced neuromuscularblockade/relaxant in the given scenario. Sugammadex is a modified γ-cyclodextrin and the first selective relaxant–binding agent based onan encapsulating principle for the inactivation of nondepolarising neuromuscular blocking drugsmainly rocuronium and vecuronium. This principle of complex formation of sugammadex androcuronium or vecuronium in a 1:1 ratio occurs at all levels of neuromuscular blockade resultingin a more fast-acting pharmacologic reversal when compared with anticholinesterase drugs likeneostigmine. Other options: Options A and B: Physostigmine and Rivastigmine are acetylcholinesterase inhibitors, which arenot effective for reversing vecuronium. Option D: Succinylcholine is a neuromuscular blocker itself and would not reverse vecuronium; itis used to induce paralysis rather than reverse it.

Answer: C. Aspartate and glutamate

Aspartate and glutamate are responsible for the negative charge in fibrinopeptide A and B offibrinogen. The negative charges contribute to the solubility of fibrinogen in plasma and importantly alsoserve to prevent aggregation by causing electrostatic repulsion between fibrinogen molecules.

Answer: A. Albinism

Albinism is inherited in an autosomal recessive pattern.

Answer: D. Tryptophan

Replacing alanine with tryptophan will increase UV absorbance of protein at 280nm wavelength The amino acids which absorb 250-290nm (maximum at 280nm) UV light are Tryptophan(Maximum Absorption), Tyrosine, Phenylalanine.

Answer: A. Mismatch repair

Mismatch repair will be defective in a patient with multiple gastrointestinal polyps andcarcinoma, with a positive family history/history of hereditary non-polyposis colon carcinoma(HNPCC) Mismatch repair is a DNA repair mechanism that corrects single-nucleotide mismatches,insertions, and deletions introduced by the DNA polymerase during DNA replication. HNPCC or Lynch syndrome is an autosomal dominant genetic condition. It occurs due to defectsin DNA mismatch repair genes like MLH1 and MSH2. The genomes of these patients showmicrosatellite instability. HNPCC is associated with a high risk of colon cancer. It may also beassociated with a risk of developing carcinomas of the endometrium, stomach, small bowel, ovary,pancreas, and transitional cell carcinoma of the ureter and renal pelvis. The diagnostic criteria for HNPCC are referred to as the Amsterdam criteria or the 3-2-1-0 rule. Itincludes: • Three or more relatives with HNPCC-associated cancer (colorectal cancer, endometrial cancer,cancer of the small bowel, ureter, or renal pelvis), one of whom is a first-degree relative of theother two. • At least two successive generations affected • At least one case diagnosed before age 50 years • Familial adenomatous polyposis excluded • Tumors verified by pathologic examination. Other options: Option B: Patients with xeroderma pigmentosum have a defect in the nucleotide excision repairpathway. Option C: Defect in base excision repair pathway is seen in patients with MUTYH-associatedpolyposis. Option D: Sickle cell disease and beta-thalassemia are examples of diseases seen in patients withpoint mutations.

Answer: A. Myophosphorylase

The clinical scenario points to a diagnosis of McArdle disease, which results due to a deficiency ofthe enzyme myophosphorylase (muscle glycogen phosphorylase). McArdle disease, also known as type V glycogen storage disorder, is an autosomal recessivecondition. It typically presents during late childhood or in the second decade of life. The muscleglycogen phosphorylase enzyme deficiency interferes with ATP generation by glycogenolysis in themuscles. This causes muscle glycogen accumulation. Symptoms are exercise intolerance associated with muscle cramps. A second wind phenomenon,where the symptoms subside after a short period of rest, can also be seen. Myoglobinuriasecondary to rhabdomyolysis leads to the passage of burgundy-colored urine in some patients. Rarely, it can present during infancy as hypotonia, muscle weakness, and respiratorycomplications. It is generally fatal. Muscle biopsy to measure glycogen content is the standard diagnosis. Avoiding strenuous exerciseprevents symptoms. Glucose administration before exercise can improve tolerance. Vitamin B6 isalso recommended. Other options: Option B - Hexokinase is a glycolytic enzyme. Its deficiency leads to hemolytic anemia.Splenomegaly may be another presenting feature. Option C - Glucose-6-phosphatase is an enzyme involved in gluconeogenesis. Its deficiency leadsto von Gierke disease also known as type I glycogen storage disease. Option D - Hepatic glycogen phosphorylase deficiency results in type VI glycogen storage disease,also known as Hers disease.

Answer: B. Factors II, VII, IX, and X

Clotting factors II, VII, IX, and X are zymogens of serine proteases that contain glutamic acidresidues. These residues undergo vitamin-K-dependent carboxylation via gamma-glutamylcarboxylase to form gamma-carboxyglutamic acid residues. These residues chelate calcium ions,allowing the binding of clotting factors to the platelet surface. Zymogens are the proprotein form of enzymes (proenzymes) that require proteolytic activation tocarry out their function. The reduced form of vitamin K acts as a cofactor in the post-synthetic modification of thesezymogens and their activation. This reduced form of vitamin K is recycled back from its oxidizedform by the enzyme vitamin K epoxide reductase, which is inhibited by warfarin. The absence of vitamin K or the presence of warfarin inhibits carboxylation of the glutamateresidues, leading to the release of abnormal precursors of clotting factors in the blood.

Answer: C. Tetrahydrobiopterin synthase

This child with phenylketonuria with neurological symptoms not improving despite dietarymodifications and normal serum phenylalanine hydroxylase level is suggestive oftetrahydrobiopterin (BH4) synthase deficiency. A diet low in phenylalanine (eg: tapioca) is the mainstay of treatment for classic phenylketonuriabut may not be sufficient in BH4 deficiency where supplementation with BH4 and deficientneurotransmitter precursors (L-dopa) is required to overcome the block. Phenylketonuria (PKU) is an inborn error of metabolism seen due to a defect in theenzyme phenylalanine hydroxylase (classic phenylketonuria) and less commonly, due to a defectin BH4 synthase (non-classical). These defects result in the impaired conversion of phenylalanineto tyrosine. The patient develops clinical features due to elevated levels of phenylalaninemetabolites and decreased levels of tyrosine. The excess phenylalanine in the blood is metabolizedto phenylpyruvate (positive ferric chloride) and phenylacetate (mousy odour) which are excretedin the urine. Infants appear normal at birth and gradually develop symptoms of hyperreflexia,seizures, hypopigmentation, low IQ, hyperactivity, and tremors. Tandem mass spectroscopy is the investigation of choice. Guthrie test is a screening test thatshows with absence of growth of Bacillus subtilis. The ferric chloride test is positive with thedevelopment of a transient blue-green colour. Other options - Option A: Tyrosine hydroxylase is the rate-limiting enzyme in the synthesis of epinephrine,converts tyrosine to DOPA, its deficiency does not cause phenylketonuria Option B: Homogentisic acid oxidase converts homogentisic acid to maleylacetoacetic acid in thetyrosine degradation pathway and its deficiency causes alkaptonuria with a dark colour of urineon standing, bluish-black pigmentation in connective tissue (ochronosis) and arthritis. Option D: Dopa decarboxylase is another enzyme involved in the synthesis of epinephrine. Itconverts DOPA to dopamine in the presence of vitamin B6. While enzymes involved inepinephrine synthesis cause neurological dysfunction, they do not cause phenylketonuria as such.

Answer: D. Designated Microscopy Centre

Among the options given, Designated Microscopy Centre is the most peripheral centre.

Answer: B. Annual Blood Examination Rate

The Annual Blood Examination Rate (ABER) is used to check the efficiency of the surveillancesystem for malaria. It takes into account the number of slides examined for the population undersurveillance.

Answer: D. White container

Sharp waste is disposed of in the puncture and leak-proof white containers.

Answer: A. Infant mortality rate

The infant mortality rate is not a component of the global hunger index. The Global Hunger Index (GHI) has three dimensions. These dimensions are measuredby indicators. GHI score = (1/3 X standardized PUN) + (1/6 X standardised CWA) + (1/6 X standardised CST) +(1/3 X Standardised CM) Where, • PUN is the proportion of the population that is undernourished • CWA is the prevalence of wasting in children under 5 years of age • CST is the prevalence of stunting in children under 5 years of age • CM is the proportion of children dying under the age of 5 years of age. The result lies on a scale from 0 to 100, with 0 meaning no hunger and 100 being the worst score.The GHI is given by the International Food Policy Research Institute. In 2021, India's GHI was27.5. It ranks 101 among 116 countries. In the 2022,India's GHI stands at 29.1, and Indiaranks 107th out of the 121 countries. DimensionsIndicators Inadequate food supplyProportion of the population undernourished Child mortalityUnder 5 mortality rate Child undernutritionWasting in children under 5 yearsStunting in children under 5 years

Answer: A. Green tea reduces the risk of diabetes

Green tea reduces the risk of diabetes mellitus is the correct statement since the risk ratio is 0.84. Relative risk (RR) or risk ratio is the ratio of the incidence of the disease (or death) amongexposed and the incidence among non-exposed. It can be determined from a cohort study. It is a direct measure of the strength of the association between suspected cause and effect. Thelarger the RR, the greater the strength of the association between the suspected factor anddisease. • RR < 1 indicates inverse association(protective effect). • RR = 1 indicates no association • RR > 1 indicates a positive association. • RR of 2 indicates a 100% increase in risk. In the question, the risk ratio is less than 1. Hence it implies the incidence of diabetes mellitus isreduced when exposed to green tea.

Answer: C. Vitamin C

The likely diagnosis based on the given clinical scenario is neurolathyrism. Administrationof vitamin C at doses of 500-1000 mg is beneficial for this. Lathyrism is a paralyzing disease of humans and animals. It is due to the consumption of khesaridal or Lathyrus sativus. When the husk is removed, it looks similar to red gram or Bengal gram. Itis mostly consumed by poor agricultural laborers because it is relatively cheap. Lathyrism is moreprevalent in parts of Madhya Pradesh, Uttar Pradesh, Odisha, and Bihar. The Prevention of FoodAdulteration Act in India has banned Lathyrus sativus in all forms (whole/ split/ flour). In humans, it is referred to as neurolathyrism because it affects the nervous system. Itis characterized by gradually developing spastic paralysis of the lower limbs. Beta-oxalyl aminoalanine (BOAA) is the toxic compound causing this disease. It is water-soluble and can beremoved by the following methods: • Soaking pulses in hot water and discarding the water • Overnight soaking in lime water, followed by boiling • Parboiling - for large-scale detoxification

Answer: B. Paired t-test

This study involves a quantitative variable, i.e., blood cholesterol, and compares the before andafter results of the same group. Hence, a paired T-test is used. Tests of significance are used to check for significant association between two or more variables.Examples are the Student t-test, Paired t-test, Chi-square test, ANOVA, and Fischer-exact test. McNemar's test is a non-parametric test for analysing paired nominal data. This test examines themarginal homogeneity of two dichotomous variables using a 2 x 2 contingency table. Oneindependent variable with two dependent groups and one nominal variable with two categories(dichotomous) are needed for the test.

Answer: D. Pars inferior

The saccule develops from pars inferior. The development of the inner ear begins in the 3rd week of fetal life and is completed by the 16thweek. The surface ectoderm on each side of the rhombencephalon thickens to form otic/auditoryplacodes, which then invaginate to form the otic vesicle (otocysts). The cells of the otic vesicle differentiate to form ganglion cells, which later develop into thevestibulocochlear ganglia. Later each otic vesicle divides into a dorsal component called parssuperior and a ventral component called pars inferior. Pars superior gives rise to the utricle, semicircular canals, and endolymphatic ducts. Pars inferiorgives rise to saccule and cochlear duct. The saccule is connected to the cochlea through a narrowduct called ductus reuniens.

Answer: C. Aspirin

In a patient with Samter's triad, aspirin should be avoided as he will have aspirin intolerance. Samter's triad is also known as aspirin-induced asthma or aspirin-sensitive asthma. It consists of: • Nasal polyposis • Bronchial asthma • Aspirin intolerance Patients with Samter's triad will have persistent nasal congestion, rhinorrhea, anosmia, nasalpolyps, and recurrent chronic rhinosinusitis. Asthma and aspirin intolerance develop later. Acute asthma attacks usually occur 3 hours after intake of aspirin or NSAIDs. Severe rhinorrhea,conjunctival injection, facial flushing, and periorbital edema are also seen. Aspirin-inducedhypersensitivity reactions also may occur. Patients should avoid aspirin and NSAIDs that inhibit COX-1. Treatment may involve aspirindesensitization and endoscopic sinus surgery.

Answer: A. Brain

Among the given options, the first organ to putrefy is the brain. The order of organ putrefaction (from first to last): • Larynx and trachea • Stomach, intestine, spleen • Liver and lungs • Brain • Heart • Kidney and the bladder • Prostate and uterus • Skin, muscle, tendons • Bones

Answer: C. 193/ BNS 229

The punishment of perjury is dealt with under IPC 193, has now been updated to BNS 229. Perjury is defined as the offence of wilfully telling an untruth or making a misrepresentationunder oath.

Answer: C. 193/ BNS 229

The punishment of perjury is dealt with under IPC 193, has now been updated to BNS 229. Perjury is defined as the offence of wilfully telling an untruth or making a misrepresentationunder oath.

Answer: B. Bradycardia

Cocaine intoxication presents with tachycardia and not bradycardia. Thus, the presence ofbradycardia would go against the diagnosis of cocaine intoxication. Cocaine is an alkaloid deliriant extracted from Erythroxylum coca. Acute intoxication with cocaine leads to symptoms spanning 2 stages- • Stage of excitement/euphoria - associated with hypervigilance, anxiety, hyperactivity along withhyper-adrenergic signs of mydriasis, tachycardia, elevated blood pressure, hyperthermia, andcardiac arrhythmias. • Stage of depression - associated with loss of reflexes, muscle paralysis, circulatory andrespiratory failure, and coma. Chronic intoxication is characterized by toxic delirium and tactile hallucination of bugs (cocainebugs) or vermin crawling under the skin (formication). Common complications include cerebrovascular accidents and myocardial ischemia. Treatment includes intravenous diazepam for controlling seizures. For ventricular arrhythmias,propranolol may be given intravenously. If the patient has psychosis, haloperidol may be given.Treatment of chronic cocaine abuse requires psychiatric support. Cocaine withdrawal is a triphasic syndrome that presents after the sudden stoppage of chroniccocaine use. The phases are as follows - • Crash phase (9 hours - 4 days): Anorexia, depression, excessive craving, hypersomnia, fatigue. • Normal mood, anxiety, and anhedonia (4 - 7 days) • Extinction phase (7 - 10 days): Absence of withdrawal symptoms but increased susceptibility torelapse. Treatment for withdrawal includes bromocriptine and amantadine. They are useful in reducingcocaine craving.

Answer: D. Letulle technique

The en masse removal of organs is done in the Letulle technique. It is the removal of the cervical, thoracic, abdominal, and pelvic organs as a single organ mass.They are subsequently dissected into organ blocks.

Answer: B. Posthumous child

The child delivered after the death of the biological father, or a child delivered after the death ofthe biological mother, usually when delivered by a cesarean section is a posthumous child. Legal issues involved with a posthumous child are legitimacy, inheritance of property, and thecase of compensation for slander against the mother. Other options : Option A: Illegitimate child is a child born out of wedlock i.e. when the parents are unmarried. Option C: A surrogate child is born out of a pregnancy in which a woman gives birth to a baby fora person who is not able to have children. Option D: Supposititious child or fictitious child is when a woman pretends to go throughpregnancy and delivery. Later, she produces a living child on her own to obtain money or claimthe property.

Answer: A. Streptococci

Patient developing endocarditis 2 years after prosthetic valve surgery suggests late-onsetendocarditis. In such cases, the most common causative organism is streptococci.

Answer: A. Subcutaneous nodule

The most common extra-articular manifestation of rheumatoid arthritis(RA) is subcutaneousnodules. The nodules are generally benign, non-tender, and firm, and occur in areas subjected to repeatedtrauma such as the forearm, sacral prominences, and Achilles tendon. They can also occur in thelungs, pleura, pericardium, and peritoneum. Patients who have a history of cigarette smoking had early onset arthritic manifestations andtested positive for RA factor or ACPA are more likely to develop extra-articular manifestations.Other common extra-articular manifestations include secondary Sjogren's syndrome, interstitiallung disease, pulmonary nodules, and anemia. FELTY’S syndrome is a triad of neutropenia,splenomegaly, and nodular RA.

Answer: A. Intrinsic asthma

Nasal polyps are associated with intrinsic asthma. Intrinsic asthma is characterized by the presence of asthma with negative skin prick tests forcommon antigens. The association of nasal polyps with asthma is described by Samter’s triad(intrinsic asthma + aspirin hypersensitivity + nasal polyposis). Asthma is usually severe,persistent, and adult-onset. Other options: Option B: Brittle asthma refers to a severe variant of asthma where patients have very serious andoften, life-threatening attacks despite appropriate therapy. Option C: Extrinsic asthma is also referred to as atopic asthma. It is allergen mediated. Option D: Exercise-induced asthma is airway narrowing due to strenuous physical activity.Symptoms typically start after the exercise has ended and last for around 30 minutes.

Answer: C. His HLA identical 50-year-old brother who is otherwise healthy and is blood type O+

In the case of acute myeloid leukemia (AML), allogeneic stem cell transplants are the treatment ofchoice. His HLA identical 50-year-old brother who is blood type O positive would be the bestchoice. Other options: Option A: An identical twin brother would not be the donor of choice. The therapeutic benefit ofstem cell transplant in hematological malignancies is due to the graft-versus-leukemia (GvL).Donor T lymphocytes attack malignant hematopoietic stem cells of the recipient that remain afterhigh-dose chemotherapy. Despite having a low rate of graft versus host disease (GvHD), stem cellsfrom an identical twin do not have a desirable degree of GvL effect, leading to higher rates ofrecurrence post-transplant. Option B: Autologous (umbilical cord transplant) is not recommended as higher rates of relapsehave been reported. Option D: An HLA identical sibling is preferred over an unrelated HLA identical donor becausethere is a greater chance of matching for minor histocompatibility complex (mHC). This reducesthe risk of GvHD. ABO compatibility is also important to consider, but a minor ABO mismatch(Rh mismatch) doesn't have any impact on hemolysis, graft-versus-host disease, or survival.

Answer: B. Class B

The given patient belongs to Child-Turcotte-Pugh class B. The score can be calculated as follows: Serum bilirubin-2.5mg/dl: 2 Serum albumin-3g/dl: 2 Prothrombin time-5 seconds or INR-2: 2 No encephalopathy: 1 Mild ascites: 2 Therefore, the Child-Turcotte-Pugh score is (2+2+2+1+2)= 9 which is included in Class B.

Answer: A. Type 1 renal tubular acidosis

The given laboratory values of low pH, low bicarbonate, low potassium and urinary pH >5.5 are suggestive of metabolic acidosis due to type 1 renal tubular acidosis (RTA). Metabolic acidosis associated with RTA I has a normal serum anion gap due to impaired urinaryacidification. It is also associated with hypercalciuria. The hypercalciuria leads to a tendency toform calcium oxalate and calcium phosphate stones. The patients can also have recurrent UTIsand hematuria. The urinary anion gap is positive in these cases, and urine pH is greater than 5.5.

Answer: B. T cell

Nude mice are not resistant to xenograft due to absence of T cell. A xenograft is a tissue graft or organ transplant from a donor of a different species. Nude mice lack body hair, hence the name. They lack a thymus and thus cannot generate matureT lymphocytes. The absence of T-lymphocytes makes them unable to mount adaptive immuneresponses requiring helper T cells and cytotoxic T cells. The absence of functioning T cells alsoprevents the rejection of allografts & xenografts.

Answer: B. Microscopic agglutination test

A history of fever with liver and kidney involvement should arouse suspicion of leptospirosis(Weil's disease). A microscopic agglutination test is used for the diagnosis of leptospirosis. Antibodies against leptospirosis appear in the blood 5-7 days after infection. Serotype-specifictests for leptospirosis includes: • Microscopic agglutination test • Macroscopic agglutination test Other options: Option A: Widal test is used to screen for typhoid fever Option C: Weil-Felix reaction is used to diagnose rickettsial fevers Option D: Paul-Bunnell test is the investigation of choice for infectious mononucleosis.

Answer: A. Staphylococcus aureus

Vomiting 2 hours after the consumption of food is likely food poisoning by Staphylococcusaureus. Staphylococcus aureus can grow in carbohydrate and protein food sources, producingenterotoxins. There are 15 types, all of which are superantigens. They are preformed toxins thatare relatively heat stable. They stimulate the vagus nerve, vomiting centre of the brain andintestinal peristaltic activity. Type A enterotoxin is responsible for most cases of food poisoning. The common sources of infection are the foods that are not cooked after handling. These includesliced meats, puddings, pastries, and sandwiches. Ingestion of such contaminated food causesfood poisoning within 30 minutes to 6 hours after consumption. Patients present with nausea,vomiting, stomach cramps, and diarrhoea.

Answer: C. Selenite F broth

The given clinical vignette of dysentery (bloody stools) and abdominal pain in a child is suggestiveof bacillary dysentery most likely caused due to Shigella. Selenite F broth is used asan enrichment media for dysentery-causing bacteria like Shigella/ Salmonella. Enrichment media: It is used to suppress commensal bacteria while allowing the pathogen to remain viable and grow.Common examples include: • Tetrathionate broth – It inhibits coliforms and allows typhoid and paratyphoid bacilli to grow. • Selenite F broth – used for dysentery causing bacteria. • Alkaline peptone water (Option-B) - used for vibrio cholera causing watery diarrhea. Other options: Robertson's cooked meat broth (Option-A): It is used for the culture of anaerobic organisms. Brain-heart infusion broth (Option-D): It is an enriched media. It is used for the cultivationof fastidious organisms. Dysentery/Shigellosis is a type of food poisoning caused by infection with the Shigella species. It isspread through faeco-oral transmission. They are catalse-negative, non-lactose-fermenting,gram-negative rods, and are non-motile. It acts by inactivating the 60s ribosomal subunit therebyinhibiting protein synthesis. It causes acute onset of symptoms(fever, abdominal cramps) withdysentery and tenesmus. It also gives a positive Sereny test.

Answer: B. Rickettsia prowazekii

The given clinical scenario is suggestive of epidemic or louse-borne typhus caused by Rickettsiaprowazekii. Pediculus corporis (human body louse) is the vector for the parasite, although the head louse mayalso transmit the disease. After the incubation period of 5 - 15 days, the disease typically startswith fever and chills. By around 4 - 5th day of fever, a characteristic rash appears, which starts onthe trunk and spreads over the limbs but spares the face, palms, and soles. The infection can be transmitted by • Contaminated louse feces rubbed through abrasions caused by scratching • Inhalation of aerosols of dried louse feces or directly through the conjunctiva The disease is often severe with the fever lasting for over 2 weeks and is more fatal in patientsolder than 40 years of age. Other options: Option A: R. typhi causes murine (flea-borne) or endemic typhus. Rats are the reservoirs ofinfection and the parasite is transmitted by Xenopsylla cheopis (flea). The infection is transmittedwhen the flea feces is rubbed into the bite wound. The clinical features are similar to that ofepidemic typhus but are milder and rarely fatal. Patients can present with fever, headache,myalgia, and rash. Option C: R. akari causes rickettsial pox, which is a mild disease resembling varicella. The diseaseis transmitted by mites and the patients may present with fever, headache, and a vesicular rash. Option D: R. conorii causes the Mediterranean spotted fever. The parasite is transmitted by ticksand the patients present with fever, headache, rash, and eschar (tache noire).

Answer: B. Microscopic agglutination test

The given clinical scenario is suggestive of leptospirosis (Weil's disease). A microscopicagglutination test is the investigation of choice for the diagnosis of leptospirosis. Leptospirosis is a zoonotic disease caused by Leptospira interrogans. Humans are infected whenthe leptospirae in water contaminated with the urine of carrier animals enter the body throughcuts or abrasions on the skin or through the intact mucosa of the mouth, nose, or conjunctiva.Hence, a sewage worker is at an increased risk of it. Clinical features include fever, jaundice, vomiting, headache, and intense injection of the eyes.Some may present as aseptic meningitis or with hepatorenal damage (Weil's disease). There aretwo clinical types of leptospirosis: icteric and non-icteric. It can also manifest as asepticmeningitis. The life cycle of Leptospira is depicted below:

Answer: C. Fimbriae

Bacteria utilise fimbriae for adherence. Fimbriae, also called pili are hair-like surface appendage that projects from the cell surface asstraight filaments. Fimbriae are classified based on the function of ordinary pili and sex pili. Functions of pili: • Bacterial adhesion of symbiotic and pathogenic bacteria to host cells using adhesins. • Resistance to phagocytosis. • Antigenic pilin proteins are responsible for the immune response. • Twitching motility to bacteria. • Bacterial conjugation through sex pili, in which transfer of genetic material occurs. Other options: Option A: The cytoplasmic membrane, or plasma membrane, is a fundamental structure of allcells, including bacteria. It acts as a selective barrier, regulating the entry and exit of substances. Option B: In organisms like protozoa, cilia are used for locomotion and feeding. These organismsuse their cilia to move through water and to sweep food particles towards their oral groove. Option D: Flagella are thread-like appendages composed of protein. They are the organs oflocomotion but motility via pili is completely different from flagellar motion because of the helicalarrangement of pilin molecules.

Answer: C. Start ART immediately and continue life-long

ART should be initiated immediately and continued lifelong in all pregnant and breastfeedingwomen with HIV. This is regardless of their WHO clinical stage and CD4 cell count. *Note: Pearl attached below has been updated according to the NACO ART guidelines 2021.Efavirenz has been replaced by Dolutegravir as per the new guidelines.

Answer: C. Asking the patient to perform the Valsalva manouvre and see if the pessary is in place

The first step after fitting the pessary to check if the pessary is adequately retained is to ask thepatient to perform Valsalva's maneuver or cough and see if the pessary is in place. There is some level of descent of the pessary with these maneuvers is to be expected, but thepessary should return to its normal position when these efforts are stopped. If the pessarydescends to the introitus with these maneuvers, then a larger size pessary should be tried. The pessary is well-fitted if you are able to slide the ring of the pessary up and down along thevaginal sidewall. It is well-fitted if you are able to insert one finger between the vaginal sidewalland the edge of the pessary. When the labia are separated, a well-supported pessary is not usuallyvisible. The patient should be comfortable, and able to void urine with the pessary in place before leavingthe clinic.

Answer: B. 126 mg/dL

Overt diabetes is when fasting blood sugar is ≥ 126 mg/dl. Overt diabetics are women who areknown to have diabetes before pregnancy. A patient is said to have overt diabetes if: • Fasting blood sugar ≥ 126 mg/dL • A random blood sugar of ≥ 200 mg/dL • HbA1c of ≥ 6.5% The maternal complication of diabetes: • increased Miscarriage and preterm labor. • increased incidence of preeclampsia • polyhydramnios • prolongation of labor due to shoulder dystocia, operative interference, and cephalo-pelvicdisproportion. Fetal and Neonatal complications of diabetes: • fetal macrosomia (birth weight > 4kg) • congenital malformations - Musculoskeletal, urogenital, and CNS anomalies.

Answer: A. Ampulla

Fertilization usually occurs in the ampulla of the fallopian tube. During ovulation, the ovum is released and it enters the fallopian tube. It is propelled towards theuterine cavity by the peristaltic action of the fallopian tubes, prostaglandins in the male seminalfluid and oxytocin. It can only be fertilized within 24 hours of ovulation. If coitus takes placeduring this period, the spermatozoa swimming up into the tubes meet the ovum in the ampulla.

Answer: C. Hysteroscopy and septoplasty

The appropriate management for a 32-year-old woman with a septate uterus is hysteroscopy andseptoplasty. Hysteroscopic septoplasty refers to the resection of the uterine septumunder hysteroscopic guidance. The septum can be resected either with a resectoscope or a laser. Itdoes not scar the uterus and avoids the necessity of cesarean sections for future pregnancies.There is a reduced risk of pelvic adhesions, compared with transabdominal approaches. A septate uterus is characterized by a septum in the endometrial cavity. It is caused by the failureof the medial segments of the Müllerian ducts to regress. This creates a permanent septum withinthe uterine cavity. The septum can project partially from the fundus or extend completely to the cervical os. It is themost common congenital uterine malformation in women with infertility. Other options: Option A: Hysterectomy is not advisable since the patient has come for infertility evaluation anddesires pregnancy. Options B & D: Laparoscopy/laparotomy and metroplasty are not preferred for the treatmentof a septate uterus due to the following: • Requirement of cesarean section for subsequent pregnancies to prevent uterine rupture. • Postoperative pelvic adhesions leading to infertility. Note: Jone's and Tompkin's metroplasties are surgeries for the septate uterus that involve atransabdominal approach. They cause uterine scarring and are hence not preferred.

Answer: A. Advise HPV vaccine

The patient's 14-year-old daughter should be advised to take the HPV vaccine. The patient's daughter is not at a higher risk for developing cervical cancer because it does not runin families. The etiology of cervical cancer is related to human papilloma virus (HPV) infection,and immunization against the virus is protective. There are three types of available HPV vaccines, Cervarix, Gardasil, and Gardasil-9. Option 2: BRCA mutation causes breast cancer, it is not related to cervical cancer. Option 3: PTEN mutation on chromosome 10 causes Cowden syndrome. Option 4: Cervical biopsy is not indicated in this scenario. CervarixGardasilGardasil-9 Characteristic and HPV subtypesBivalent16,18Quadrivalent 6,11,16,18Nonavalent 6,11,16,18,31,33,45,52,58 Protects againstCIN, Ca cervixAnogenital warts, CIN, Ca cervixAnogenital warts, CIN, CA cervix, Vulval intraepithelial neoplasia, Vaginal intraepithelial neoplasia Dose0.5 mL0.5 mL0.5 mL Administration0, 1, 7 months IM0, 2, 6 months IM0, 2, 6 months IM Administered genderFemale andmaleFemale andmaleFemale andmale Ideal age range (Routine recommendation by CDC)11–12 years11–12 years11–12 years9–15 years - FDA approved ACIP age recommendation in previously unimmunized women 13–26 years13–26 years13–26 years

Answer: D. Can terminate pregnancy upto 24 weeks for sexual assault

According to the MTP Act with 2021 amendments, pregnancy can be terminated upto 24 weeks ofgestation in victims of rape and incest, fetal anomalies, or congenital malformations.

Answer: D. Ptosis

The given clinical scenario is suggestive of myasthenia gravis and ptosis is the most commonocular feature of the disease. Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction mostcommonly caused by anti-acetylcholine receptor antibodies. The disorder is characterized byweakness and fatigability of skeletal muscles where the weakness increases during repeateduse and may improve following rest. Ptosis and diplopia are common initial complaints due to early involvement of the lids andextraocular muscles (EOMs). Of them, Ptosis is a more common manifestation than diplopia.Ptosis in myasthenia gravis is insidious, bilateral, and frequently asymmetrical. Investigations of myasthenia gravis include: • Ice pack test -This tests for a transient improvement of the ptotic eyelid on placing an ice packfor 2 minutes, as the cold inhibits the breakdown of acetylcholine by acetylcholinesterase. • Tensilon (Edrophonium) test - This tests for a transient improvement in the weakness onadministration of a short-acting anticholinesterase such as edrophonium. • Antibody testing - for Acetylcholine receptor (AChR) antibodies, MuSK protein antibodies helpssupport a diagnosis of myasthenia gravis.

Answer: D. Vincristine, carboplatin and etoposide

Chemotherapy commonly used is a three-drug regimen containing vincristine, carboplatin, andetoposide.

Answer: D. Satellite lesion

Satellite lesions are characteristic of fungal ulcer. The signs of a fungal ulcer include: • Irregular margins of the ulcer. • Presence of satellite lesions surrounding the ulcer. • An immune ring (Wesseley) may be seen around the ulcer due to deposition of the immunecomplexes. • Slough is usually dry, with feathery borders surrounded by a yellow line of demarcation. • Hypopyon may be present or absent. If present, it is thick, immobile due to the direct invasion ofthe fungal hyphae into the anterior chamber.

Answer: B. Thyroid ophthalmopathy

The given clinical scenario is suggestive of thyroid ophthalmopathy. Thyroid eye disease (TED) is the most common cause of both bilateral and unilateral proptosis inan adult in the euthyroid state. The main features of TED include lid retraction, proptosis,periorbital edema, chemosis, and restrictive myopathy. Other options- Option A- Orbital pseudotumor presents with painful eye movements periorbital edema,erythema, proptosis, ptosis, diplopia. Option C- Orbital lymphoma usually presents in the 7th decade, most commonly observed as apainless palpable mass in the superolateral quadrant. Option D- Orbital cellulitis is usually a unilateral condition with pain, proptosis, and chemosis. NOTE: Thyroid eye disease can also, though less commonly, occur in euthyroid patients.

Answer: B. Latanoprost

Latanoprost is a prostaglandin drug, which acts by increasing the uveoscleral outflow and therebylowers the intraocular pressure. Mechanism of action: Latanoprost is a prodrug and gets activated during its passage through thecornea. It acts by stimulating the prostanoid receptors on the ciliary muscles. This leads to therelease of matrix metalloproteinases, which increases the uveoscleral outflow.

Answer: A. Lunate is dislocated anteriorly but the rest of the carpals remains in position

Among the given options, statement A is incorrect. A fall on a dorsiflexed hand may tear the tough ligaments that normally bind the carpal bones,leading to dislocations. In peri-lunate dislocation, the lunate remains in position in the lunatefossa of the distal radius but the rest of the carpals dislocate dorsally. It is frequently associatedwith compression of the median nerve. Prompt reduction reduces swelling and potential damage to the median nerve. The Taverniermaneuver is the most commonly used method of closed reduction. It involves locking the capitateinto the distal concavity of the lunate. If the injury cannot be reduced using this method, urgentreduction in the theater should be performed. In lunate dislocation, the lunate dislocates anteriorly while the rest of the carpal bones remain inplace.

Answer: A. Epiphyseal plate

A fracture line passing through the epiphyseal plate (also known as the growth plate) will impairthe longitudinal growth of the bone. The epiphyseal plate is the area of growing tissue near the ends of the long bones in children andadolescents. It is responsible for bone lengthening (longitudinal growth). If the fracture involvesthe epiphyseal plate, it can disrupt this process and lead to growth disturbances or deformities. Other options: Option B: The epiphysis is the end of a long bone. While fractures involving the epiphysis canaffect joint function, they don’t directly impair longitudinal growth unless the epiphyseal plate isinvolved. Option C: The metaphysis is the region of bone between the diaphysis and the epiphysis, wherebone growth in width occurs. A fracture here doesn’t directly impact longitudinal growth. Option D: Diaphysis describes the shaft of the bone. A diaphyseal fracture typically affects thestrength and structural integrity of the bone but doesn’t impair longitudinal growth.

Answer: B. Follows autosomal dominant mode of inheritance

Ataxia telangiectasia (AT) or Louis–Bar syndrome is an autosomal recessive disorder. The defect in AT is in the ATM gene localized to chromosome 11q22-23. The ATM gene is involvedin the repair of double-strand DNA breaks. This defect in DNA repair leads to combinedimmunodeficiency (impaired immunoglobin isotype switching and association with thymichypoplasia) and predisposition to an increased risk of lymphoreticular tumors such as lymphomaor leukemia. AT is characterized by progressive ataxia (beginning during infancy), telangiectasia (initially onbulbar conjunctiva), sinopulmonary infections, hypogonadism, sensitivity to ionizing radiation,insulin resistance, and raised alpha-fetoprotein levels.

Answer: A. Age >10 years

Age >10 years indicates a poor prognosis in ALL. Leukocyte count <50,000/mm3, hyperdiploidy, and trisomy of chromosomes 4,10,17 indicate agood prognosis.

Answer: D. Weight for height less than - 3SD

Severe acute malnutrition (SAM) is best defined as weight for height less than median minus -3SD Severe acute malnutrition (SAM) in children of ages 6 to 59 months is defined by the WHO as anyof the following: • Weight-for-length (or height) below −3 SD of the median WHO child growth standards. • Presence of bipedal edema • Mid-upper arm circumference <11.5 cm Once the child is diagnosed with severe acute malnutrition, the doctor must assess for severeedema (+++); low appetite (failed appetite test); medical complications (severe anemia,pneumonia, diarrhea, dehydration, cerebral palsy, tuberculosis, HIV, heart disease, etc.) and oneor more danger signs as per IMNCI If any of the complications are present, the child is diagnosed with complicated SAM and ismanaged inpatient in the facility. If the above-mentioned signs are absent, the child is diagnosed with uncomplicatedSAM and supervised management at home is given.

Answer: A. Perinatal transmission

The most common cause of HIV infection in a newborn is perinatal transmission. Around 70 to80% of affected children acquire the virus intrapartum. The mechanism of perinatal transmission has been postulated to be mucosal exposure to infectedblood and cervicovaginal secretions in the birth canal. The intrauterine contractions during activelabor/delivery could also increase the risk of late micro transfusions. Vertical transmission of HIV can occur in utero (during pregnancy), during delivery (perinatal),and after birth by breastfeeding (least common). The risk factors for vertical transmission are high maternal viremia, preterm delivery (<34weeks), vitamin A deficiency, prolonged rupture of membranes (>4 hours) low birth weight,and low maternal CD4 count.

Answer: B. Antibiotic prophylaxis

Antibiotic prophylaxis is provided to the close contacts of persons with confirmed meningococcaldisease. Close contacts of individuals with confirmed meningococcal disease are at an increased risk ofdeveloping the illness. Prophylaxis is also offered to individuals with direct and prolonged contactwith a case of meningococcal disease. Antibiotics are effective in preventing additional cases byeradicating the carriage of the invasive strain. Treatment is provided to the contacts within 24 hours of identification of the index case. Theantibiotics effective include rifampicin, ciprofloxacin, ceftriaxone, and azithromycin. Prophylaxis is not generally recommended for medical personnel, except in cases where there isexposure to aerosols of respiratory secretions, such as during mouth-to-mouth resuscitation,intubation, or suctioning. This recommendation applies within 24 hours before or after theinitiation of antibiotic therapy in the index case. For the treatment of cases, penicillin is the preferred drug, but ceftriaxone or otherthird-generation cephalosporins are recommended for patients with penicillin allergy. Dropletinfection control precautions should be followed for hospitalized patients for 24 hours aftereffective therapy has been initiated. Offering quadrivalent meningococcal A, C, W, Y conjugate vaccines in addition to antimicrobialprophylaxis can further reduce the risk of disease among close contacts of cases caused by vaccinecapsular groups. Meningococcal vaccines are available in two forms: polysaccharide vaccines andpolysaccharide-protein conjugate vaccines. Polysaccharide vaccines can be given as a single doseto individuals aged 2 years and older. They are offered in bivalent (A, C), trivalent (A, C, W135),and quadrivalent (A, C, W135, Y) formulations. Meningococcal conjugate vaccines are available as monovalent (A or C) or quadrivalent (A, C,W135, Y) formulations. Conjugate vaccines, which offer increased immunogenicity and potentialfor herd protection, are preferred over polysaccharide vaccines, especially in children under 2years of age. Both types of vaccines are safe to use during pregnancy.

Answer: B. Biliverdin

The greenish-black color of the first stool in the newborn is due to biliverdin. Meconium is a dark, viscous material that is normally present in the intestine of the fetus andpassed within 1st 48hour of life. Meconium appears after the 20th week and at term, it isuniformly distributed throughout the gut up to the rectum indicating the presence of intestinalperistalsis. It is composed of various products of secretion, such as desquamated fetal cells,glycerophospholipids from the lungs, lanugo, scalp hair, vernix, and undigested products fromswallowed amniotic fluid. The greenish-black color of meconium is due to the presence of bilepigments excreted by the biliary tract, especially biliverdin (pigment from the oxidation ofbilirubin). During intrauterine hypoxia, the relaxation of the anal sphincter due to vagal stimulation can leadto the passage of meconium into the amniotic fluid. Additionally, the release of argininevasopressin (AVP) from the fetal pituitary gland due to intrauterine hypoxia can stimulate thecolon muscles to contract, resulting in intraamniotic defecation. Meconium aspiration syndromecan occur when meconium is inhaled, as it is toxic to the lungs. Other options: Option A: Bilirubin is responsible for the yellow color of the stools. Option D: Neonates do not harbor gut flora at birth.

Answer: D. Gastric adenocarcinoma

Gastric adenocarcinoma is an epithelial tumor of the stomach. Adenocarcinoma is the most common malignancy (90% cases) of the stomach. Option A: Carcinoid tumor is a neuroendocrine tumor. Option B: Lymphoma is a lymphoid tumor. Option C: GIST is the most common mesenchymal tumor of the abdomen.

Answer: C. 6 hours

The maximum duration for TRALI (transfusion-related acute lung injury) to occur after bloodtransfusion is upto 6 hours. TRALI is sudden-onset respiratory failure that occurs during or soonafter blood transfusion. The pathogenesis involves a two-hit hypothesis: • Priming event - increased sequestration and sensitization of neutrophils in the microvasculatureof the lung • Second hit - the factor (most commonly MHC class I antigens) present in the transfused bloodproduct activates the primed neutrophils

Answer: C. Elastase

α1-antitrypsin is the major inhibitor of the enzyme neutrophil elastase. • Lysosomal enzymes, if unchecked, can potentiate further inflammation by damaging tissues. • These harmful proteases, however, are normally controlled by a system of antiproteases in theserum and tissue fluids. • α1-antitrypsin is the prototype member of the serine protease inhibitor (serpin) superfamily ofproteins. Clinical correlate: • Alpha 1 anti-trypsin deficiency (α1-ATD) is caused by mutations in the SERPINA1 gene located inthe long arm of chromosome 14. • This genetic defect alters the configuration of the α1-antitrypsin molecule and prevents itsrelease from hepatocytes. • As a result, serum levels of α1-antitrypsin are decreased, leading to low alveolar concentrations,where the α1-antitrypsin molecule normally would provide protection against proteases suchneutrophil elastase. • The resulting protease excess in alveoli destroys alveolar walls and causes emphysema.

Answer: D. Chronic alcoholism

The given findings are suggestive of macrocytic anaemia, which can be seen in chronic alcoholics. Anemic patients with a peripheral smear showing macrocytic RBCs and hypersegmentedneutrophils are important characteristic features of megaloblastic anemia. Chronic alcoholics also have deficiency of folic acid due to: • Trapping of folate within the liver • Excessive urinary loss • Disordered folate metabolism • Inadequate dietary intake is frequently encountered in chronic alcoholics

Answer: A. Leukemia

Occupational exposure to benzene predisposes to leukemia. The given clinical history of repeatedinfections, easy fatigability, weight loss, and evening rise of temperature with benzene exposurepoints towards a diagnosis of leukemia. Benzene is oxidized to an epoxide through hepatic CYP2E1. The epoxide and other metabolitesdisrupt progenitor cell differentiation in the bone Synopsis and lead to Synopsis aplasia and acutemyeloid leukemia. Acute myeloid leukemia is a tumor of hematopoietic progenitors caused by acquired oncogenicmutations that impede differentiation. This leads to the accumulation of immature myeloid blastsin the Synopsis. The replacement of the Synopsis with blasts produces Synopsis failureand complications related to anemia, thrombocytopenia, and neutropenia. Other options: Option B: Exposure to arsenic and its compounds, asbestos, beryllium and its compounds,chromium compounds, nickel compounds, radon, and its decay products can cause lung cancer. Option C: Exposure to aryl amines, particularly 2-naphthylamine and related compounds,cyclophosphamide, cigarette smoking, irradiation can cause bladder cancer. Option D: Exposure to UV rays, arsenic, and its compounds can cause skin cancer.

Answer: A. Alpha-1 antitrypsin

Alpha-1 antitrypsin deficiency is associated with panacinar emphysema. Panacinar or panlobular emphysema is associated with α1 antitrypsin (α1AT) deficiency. It isexacerbated by smoking. Panacinar occurs more commonly in lower zones and the anteriormargins of the lung. In this type, the acini from respiratory bronchiole to terminal blind alveoliare uniformly enlarged. α1AT deficiency is an autosomal-recessive disorder of protein misfolding. Deficiency of α1ATprotein results in excessive degradation of alveoli by neutrophil elastase causing panacinaremphysema. It also causes liver disease as a consequence of the abnormal accumulation of themisfolded protein within hepatocytes. α1AT deficiency is characterized by the presence ofround-to-oval cytoplasmic globular inclusions in hepatocytes. These hepatocytes arestrongly Periodic acid–Schiff positive and diastase resistant. Trypsin, chymotrypsin, and elastase are endopeptidases. They cleave the internal peptide bonds.Trypsin is specific for cleavage at the sites of basic amino acids, while chymotrypsin and elastaseare specific for cleavage at neutral amino acids. Other options: Option B: Elastase is inhibited by alpha-1 antitrypsin. In the case of alpha 1 antitrypsin deficiency,there is the destruction of lung tissue (elastin) by the elastase released by macrophages. Option C: Chymotrypsin degrades trypsin and protects the pancreas from trypsin-related injury. Option D: Type 2 surfactant deficiency is associated with respiratory distress syndrome as type 2pneumocytes produce the surfactant which decreases the surface tension.

Answer: C. Nitrates

The patient would be on nitrates for angina and thus should not be prescribed sildenafil assildenafil causes dangerous potentiation of nitrate action resulting in severe hypotension. The combination of the two drugs has a synergistic action on the intracellular cGMP levels thatcan result in uninhibited vasodilation and a precipitous fall in blood pressure. Hence, the use ofsildenafil is a contraindication when on nitrates.

Answer: B. Brimonidine

The use of brimonidine is unsafe in infants. It is an alpha-2 agonist that can cross the blood-brainbarrier. This may result in CNS depression and apnoea in neonates. Therefore it iscontraindicated in children less than 2 years. α2 agonists, through the activation of G-protein coupled receptor activation, inhibit the activity ofadenylate cyclase. This reduces cAMP and hence reduces aqueous humor production by ciliaryaction.

Answer: C. Thiazides increase the tubular reabsorption of lithium

Thiazides act by increasing the tubular reabsorption of lithium. Thiazide use is accompanied by sodium loss which is compensated in a few days by increasedreabsorption of Na+ in the proximal tubule. The kidney handles both lithium and Na+ in the same way. Thus, along with Na+ reabsorption,there will be an increase in the reabsorption of lithium also, resulting in decreased excretion oflithium.

Answer: C. Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme (ACE) inhibitors should be discontinued in pregnancy as they cancause hypoplasia of organs, growth retardation, and fetal loss. ACE inhibitors cause reduced perfusion and oligohydramnios leading to fetal growth retardation,calvarium maldevelopment, hypoplasia of lungs and kidneys, and limb contractures. Antihypertensive drugs to be avoided in pregnancy: • ACE inhibitors and Angiotensin receptor blockers(ARB) - Can cause growth retardation and fetaldamage. • Diuretics - Can decrease uteroplacental perfusion • Nonselective beta-blockers • Sodium nitroprusside - It is contraindicated in eclampsia. Antihypertensive drugs that can be used in pregnancy: • Labetalol - Combined α + β blocker • Nifedipine - Dihydropyridine calcium channel blocker. It is useful in preeclampsia but should bestopped before labor as they weaken the uterine contractions. • Methyldopa • Hydralazine Note: Thiazide diuretics like hydrochlorothiazide are considered to be safe in pregnancy and are usefulin the management of chronic hypertension in pregnant women.

Answer: A. DNA gyrase inhibition

In the above scenario, the antimicrobial prescribed for urinary tract infection, which has apropensity to cause tendon rupture and arthropathy, is likely to be a fluoroquinolone. Themechanism of action of the drug is DNA gyrase inhibition. Normally, during replication, to prevent excessive positive supercoiling of the strands, DNAgyrase nicks double-stranded DNA and introduces negative supercoils. Fluoroquinolones, byinhibiting DNA gyrase (in gram-negative bacteria), result in the production of damaged DNA. Thisis finally digested by exonucleases, resulting in bactericidal action. Fluoroquinolones inhibit topoisomerase IV in gram-positive bacteria. Fluoroquinolones are used in the treatment of urinary tract infections, prostatitis, andgastrointestinal, respiratory infections, and as a second-line drug in anti-tubercular therapy. Theyare avoided in children and pregnant women. Adverse effects of fluoroquinolones are arthralgia, tendon rupture, Clostridium difficile colitis,dysglycemia, prolonged QT interval, rashes, hallucinations, delirium, and seizures. Other options: Option B: Ribosomal inhibition is the mechanism of action of various antimicrobials liketetracyclines, aminoglycosides, chloramphenicol, and macrolides. Option C: Cell wall synthesis inhibition is done by beta-lactam antibiotics. Option D: Inhibition of folic acid synthesis is the mechanism of action of sulfonamides andco-trimoxazole.

Answer: A. Carboprost

The drug that should be avoided in the management of postpartum hemorrhage in this motherwith a history of bronchial asthma is carboprost. Carboprost is an analog of PGF2α. It is used in obstetrics to induce second-trimester abortionsand to control postpartum hemorrhage. Vomiting, diarrhea, and bronchoconstriction can occur. Contraindications of carboprost: AbsoluteRelative AsthmaPulmonary hypertensionSuspected amniotic fluid embolism Pre-eclampsiaRenal diseaseLiver diseaseHeart disease Other options : Option B: Oxytocin is the first-line drug to prevent and treat PPH according to WHO guidelines. Itis administered by intravenous route and may lead to hypotension and reflex tachycardia. Option C: Dinoprostone is a prostaglandin E2 analog used for cervical ripening, induction oflabor, and in atony treatment. It should be avoided in patients with a history of asthma,glaucoma, or myocardial infarction. One major adverse effect is uterine hyperstimulation. Option D: Ergot derivatives are used in the control of postpartum uterine bleeding. It is givenintramuscularly and is effective within 1–5 minutes. It is given at the time of delivery of theplacenta or immediately after if bleeding is significant. Side effects are gastrointestinaldisturbances like diarrhea, nausea, and vomiting.

Answer: A. Bortezomib

The drug used to treat multiple myeloma and that has the potential to cause reactivation ofHerpes Zoster is bortezomib. Bortezomib is an inhibitor of proteasome-mediated protein degradation. It is central to thetreatment of multiple myeloma, both untreated and relapsed. Bortezomib is given intravenouslyor subcutaneously and dosage depends upon the disease, route of administration, and thepatient’s history. It is known to predispose patients to the reactivation of herpesvirus, includingHerpes Zoster. Adverse effects include thrombocytopenia, fatigue, peripheral neuropathy, neutropenia, anaemia,anorexia, nausea, limb pain, dizziness, etc. Other adverse events like cardiac tamponade,disseminated intravascular coagulation, toxic epidermal necrolysis, etc. have been reported. Other options: Option B: Lenalidomide is the drug of choice in patients with myelodysplastic syndrome (MDS)associated with 5q deletion, and is an immunomodulatory analogue of thalidomide. It suppressesbone Synopsis and is often associated with significant leukopenia. Option C: Daratumumab is a monoclonal antibody against CD-38. Option D: Elotuzumab is a monoclonal antibody against SLAMF7, a glycoprotein expressed inmultiple myeloma cells and natural killer cells. It is used in combination with lenalidomide anddexamethasone for the treatment of multiple myeloma.

Answer: C. Sodium outflow in thin ascending limb

Thin ascending limb is not a component of the countercurrent mechanism. The loop of Henle function as countercurrent multipliers and vasa recta as countercurrentexchangers. The functioning of the loop of Henle depends upon: • High permeability of the thin descending limb to water ( via aquaporin-1) • Active transport of Na+ and Cl- from the thick ascending limb • Inflow of tubular fluid from proximal tubule and outflow to the distal tubule. Note: The thin ascending limbs of juxtamedullary nephrons are permeable to Na+ and Cl- andhence do contribute passively to countercurrent multiplication. However, among the optionsprovided, Option C is the best answer as the other options are directly responsible for thecountercurrent mechanism.

Answer: D. Secondary active transport

Glucose is absorbed in the intestine by secondary active transport (sodium co-transport). The energy for glucose transport is provided indirectly, by the active transport of Na+ out of thecell. This maintains the concentration gradient across the luminal border of the cell so that moreNa+ and consequently more glucose enter. Though both secondary active transport and facilitated diffusion play a role in glucose absorption,it is the initial active transport of sodium through the basolateral membranes of the intestinalepithelial cells that provide the eventual force for moving glucose through the membranes as well.So, secondary active transport is the single best answer for this question.

Answer: D. It is characterized by flexion of upper limbs and extension of lower limbs

• Removal of the cerebral cortex (decortication) produces decorticate rigidity. • Characterized by flexion of the upper extremities at the elbow and extensor hyperactivity in thelower extremities. • The flexion can be explained by active rubrospinal excitation of flexor muscles in the upperextremities; the hyperextension of lower extremities is due to the same changes that occur aftermidcollicular decerebration.

Answer: B. 24 hours after delivery

Among the given options, the prolactin level is highest 24 hours after delivery. The maximum level of prolactin is seen during pregnancy and in the immediate postpartumperiod. During pregnancy, the secretion is increased reaching a peak at the time of delivery. Afterdelivery, the plasma concentration falls to nonpregnant levels in a few weeks. Suckling producessurges of prolactin release.

Answer: A. Adenylyl cyclase

Beta 2 receptor action leading to hypoglycemia/ hyperglycemia is mediated by adenylyl cyclase.Catecholamines act through beta 2 receptors and they use adenylyl cyclase - cAMP secondmessenger system to stimulate the target tissues. Other hormones that use adenylyl cyclase - cAMP second messenger system are : • Adrenocorticotropic hormone • Angiotensin II • Corticotropin-releasing hormone • Calcitonin • Follicle-stimulating hormone • Glucagon • Growth hormone-releasing hormone • Human chorionic gonadotropin • Luteinizing hormone • Parathyroid hormone • Secretin • Somatostatin • Thyroid-stimulating hormone • Vasopressin Hormones exert their actions by stimulating cAMP production within the cells. When thehormone binds to the membrane receptor, the receptor is coupled to the G protein. This G proteincan either stimulate (Gs protein) or inhibit (Gi protein) adenylyl cyclase that controls theconversion of cytoplasmic adenosine triphosphate to adenosine monophosphate (cAMP). Theprotein kinases dependent on cAMP are thus activated. This leads to a series of biochemicalreactions enabling the hormone to exert its actions. Guanylyl cyclase is the enzyme that catalyzes the formation of cGMP.

Answer: C. A fibers are more susceptible to pressure changes than C fibers.

In the above scenario, the patient has developed paresis (partial paralysis) but the pain sensationis intact (no numbness). This is because A fibers that carry motor, touch, and pressuresensations are more susceptible to pressure changes/compression than C fibers that carry painsensations. The compression of a large diameter nerve fiber leads to a reversible physiologic conductionblock or neuropraxia. The relative susceptibility of nerve fibers to conduction blocks produced by various agents: SusceptibilityMost susceptibleIntermediateLeast susceptible Local anestheticCBA HypoxiaBAC PressureABC

Answer: B. Receptive Speech Function

A posterior lesion in Brodmann's area 22, which is located in the superior temporal gyrus,typically affects receptive speech function. It is the sensory speech area. The patient will most likely have Wernicke’s aphasia due to the damage to Wernicke’s area - area22. In Wernicke's aphasia, there is difficulty in finding words leading to poorly understood content forthe listener. These patients also find it difficult to repeat sentences and name things properly. It isa type of fluent aphasia in which the speech is easy and fluent but there are difficulties related tothe output of language like paraphasia (substitution of similar-sounding, non-words, or incorrectwords). The speech is full of jargon and neologisms (non-existent words) that make little sense. Other options: Option A: Auditory Function is primarily mediated by Brodmann area 41, which is located in theprimary auditory cortex within the superior temporal gyrus. Option C: Expressive Speech Function is associated with Brodmann areas 44 and 45 (Broca'sarea), which are involved in language production and speech articulation. Lesions here can causedifficulty in producing coherent speech (Broca's aphasia). Option D: Visual function primarily associated with Brodmann areas 17, 18, and 19 (the primaryand secondary visual cortices).

Answer: D. Post traumatic stress disorder

The given clinical scenario is suggestive of post-traumatic stress disorder. PTSD is a psychiatricdisorder occurring after a life-threatening or potentially fatal event, (e.g., war, house fire, seriousaccident, rape, robbery) affecting the patient or the patient’s close friend or relative. Symptoms can be divided into four types: • Re-experiencing (e.g., intrusive memories of the event [flashbacks] and nightmares) • Hyperarousal (e.g., anxiety, increased startle response, impaired sleep, hypervigilance) • Negative cognition (e.g., negative beliefs, emotional numbing) • Avoidance (e.g., avoiding stimuli associated with the traumatic event) Psychotherapies found to be effective for PTSD include exposure therapy, trauma-focusedcognitive-behavioral therapy, eye movement desensitization, and reprocessing.

Answer: B. Fluctuating course

Fluctuating course is suggestive of delirium. Characteristic presentation of delirium: • Acute onset • Brief duration - usually days to weeks • Decline in the level of consciousness. • Fluctuating course - unpredictable fluctuations in severity and other clinical manifestations • Sundowning - worsening of symptoms at night • Rapid improvement - when the underlying cause is treated • Other characteristics include asterixis, carphologia (picking movements on cover sheets andclothes) • More commonly associated with visual hallucinations

Answer: D. Young age

Advanced age is a risk factor for delusional disorders, not young age. Risk factors for delusional disorders: • Advanced age • Sensory impairment or isolation • Personality features (e.g.unusual interpersonal sensitivity) • Family history • Social isolation • Recent immigration

Answer: C. Orgasm

Premature ejaculation is a disorder of the orgasm phase of the normal sexual cycle. Premature ejaculation is when ejaculation occurs before the completion of satisfactory sexualactivity. In severe cases, it is characterized by ejaculation either before penile entry into the vaginaor soon after penetration. The causes can be biological or psychological, like performance anxiety.

Answer: D. Support and education

Postpartum blues is common in mothers in the puerperal period and requires nothing more thaneducation and support. It is characterised by a labile mood, sadness and subjective confusion. It isthought to be due to changes in hormone levels, the stress of childbirth and anxiety about theresponsibilities of motherhood. If symptoms last longer than 2 weeks, an evaluation for postpartum depression is needed.

Answer: B. Psychomotor

The type of learning seen in this case is psychomotor learning. The psychomotor domain includes learning by observation, physical movements, and the usage ofmotor skill areas of the brain. The development of these skills requires practice, depending uponthe complexity of the task. It is measured based on speed, precision, distance, and procedures inexecution. The three domains in learning are the cognitive, psychomotor, and affective domains. They aredescribed as follows. Cognitive learning includes the domain of knowledge. Bloom's taxonomy described six levels ofcognitive skills. This was revised to include types of knowledge and cognitive processes. Thecognitive processes include remembering, understanding, applying, analyzing, evaluating, andcreating. Eg. Solving multiple-choice questions in the NEET PG entrance exam involves the usageof the cognitive domain. Psychomotor learning includes the domain of skills. It includes imitation, manipulation,precision, articulation, and naturalization. Eg. Learning how to insert an IV cannula by observingthe residents and nurses during the internship involves the usage of the psychomotor domain. Affective learning includes the domain of attitude and values. It includes receiving, responding,valuing, organizing, and characterization by value. Eg. Communicating with patients withempathy, responding to their concerns, and interacting with the relatives of patients involves theusage of the affective domain. Integration of all these three methods in teaching and learning methodology leads to a betterunderstanding of the subject.

Answer: A. Total Anomalous Pulmonary Venous Connection

Plethoric lung fields are seen in Total Anomalous Pulmonary Venous Connection (TAPVC). In thiscondition, pulmonary venous obstruction results in pulmonary arterial hypertension, resulting inplethoric lung fields. Increasedpulmonary blood flow (pulmonary plethora)Decreasedpulmonary blood flow AcyanoticVentricular septal defect, Atrial septal defect, Patent ductus arteriosus — CyanoticTAPVCEbstein anomaly, Tetrology of Fallot, Tricuspid atresia

Answer: D. E.coli

The most common organism causing acute bacterial prostatitis (ABP) is Escherichia coli. It is commonly caused by an ascending urethral infection or reflux of infected urine into prostaticducts. Sexually transmissible infections and other urinary pathogens, such as Staphylococcusaureus and Streptococcus faecalis may also be responsible. The patient presents with fever, perineal pain, chills and rigor, and dysuria. Per rectalexamination will reveal a tender, boggy prostate. Care should be taken to avoid aggressivepalpation or prostatic massage as it can lead to bacterial dissemination and sepsis. Urine examination and culture should be done. Urine examination reveals threads in urine. Management: Patients with systemic signs of infection should be admitted for IV antibiotics, hydration, andmonitoring of laboratory parameters. Patients who have no signs of systemic infection, who can tolerate oral intake, and who have nourinary retention can be treated with oral antibiotics. Antibiotics are given for 2-6 weeks to ensurethe eradication of the infection as antibiotics don't penetrate the prostate capsule easily. For outpatient therapy: Ciprofloxacin 500 mg oral every 12 hours or levofloxacin 500 mg OD ortrimethoprim-sulfamethoxazole double-strength tablet oral every 12 hours can be used. For hospitalized patients: Intravenous ciprofloxacin or levofloxacin with or without anaminoglycoside (gentamicin or tobramycin) or intravenous beta-lactam with or without anaminoglycoside. Gram-positive infections are treated with cephalosporins (cephalexin, cefazolin)or dicloxacillin and vancomycin.

Answer: B. Microdochectomy

Microdochectomy is the excision of the entire lactiferous duct (single duct disease). It is done forduct papilloma. Microdochectomy: • In a duct papilloma where no palpable mass is present, the duct is expressed to observe thedischarge. • A fine probe or stiff nylon suture is gently inserted into the duct, and the probe is secured to thenipple skin using silk sutures to prevent displacement during the procedure. • A tennis racquet shaped incision is made to elevate the skin flaps, and the duct with the probe isexcised along with the skin flap for 5 cm until the papilloma is identified (The papilloma willalways be located within 5 cm from the duct orifice). • The wound is closed without a drain, and a compression bandage is applied. It is ideal to rule out DCIS by frozen section biopsy. Cone excision and wide excision are done under major duct excision (Adair-Haldfield operation).It is done for duct ectasias with multiple duct involvement and multiple papillomas.

Answer: B. Zenker’s diverticulum

Dohlman’s procedure is done for Zenker’s diverticulum. It is a transoral endoscopic approach, that ablates the septum between the diverticulum and thecervical esophagus. It can be used for diverticula between 2 and 5 cm in size. Other options: Option A: Meckel’s diverticulum is a remnant of the vitellointestinal duct and is treated bysurgical resection. Option C: Bochadlek’s hernia is a congenital posterolateral defect on the left side of the diaphragmdue to defective embryological development. Option D: Menetrier’s disease is a premalignant condition with gross hypertrophy of gastricmucosal folds and is treated with gastrectomy.

Answer: C. Auriculotemporal nerve

The auriculotemporal nerve (V3 nerve) is involved in Frey's syndrome (gustatory sweating). Frey’s syndrome is also known as Dupuy syndrome or auriculotemporal syndrome. It commonlydevelops after parotid surgery. It is caused by an aberrant regeneration of post-ganglionicparasympathetic nerve fibers crossed along the sympathetic pathways to the sweat glands near theparotid region. Clinical features are due to the result of salivary stimulation (by the smell or taste of food) leadingto the sweating and flushing of the periauricular region on the involved side of the face. A starchiodine test is used for diagnosis. Treatment ranges from antiperspirants (in mild cases) to tympanic neurectomy or botulinumtoxin injection (in severe cases). It can be prevented by incorporating careful extracapsulardissection and closure of the superficial musculoaponeurotic layer during parotidectomy. Other options: Option A: Facial nerve is the 7th cranial nerve that supplies the muscles of the face, and results infacial paralysis if injured during parotidectomy Option B: Oculomotor is the 3rd cranial nerve which supplies the extraocular muscles. If injuredduring ophthalmic surgeries, it results in ocular paralysis and the eye pointing down and out. Option D: Glossopharyngeal nerve is the 9th cranial nerve and its injury causes loss of tastesensation from the posterior 1/3rd of the tongue.

Answer: B. Arterial disease with aortoiliac involvement

The given clinical scenario is suggestive of arterial disease with aortoiliac involvement. Classically,the muscle group affected by claudication is one anatomical level below the level of arterialdisease. Intermittent claudication is a feature of chronic arterial disease or occlusion of the artery. Aortoiliac disease affects the infrarenal aorta and iliac arteries. Management involves smoking cessation, lifestyle modifications, and treatment of underlyingdiabetes or hyperlipidemia if present. For claudication, cilostazol or pentoxyfilline is used. Cilostazol is superior to pentoxyfilline. Surgical options include aortoiliac bypass, aortobifemoral bypass, percutaneous transluminalangioplasty (PTA), which can be with or without stent placement, and thromboendarterectomy. Correlation of clinical findings to the Site of Disease Aortoiliac obstructionClaudication inbuttocks, thighs, and calvesBruit over the aortoiliac regionImpotence(Leriche's syndrome) Iliac obstructionClaudication ofthigh and calf,unilaterallyAbsence of femoral and distal pulsesBruit over iliac region Femoropopliteal obstructionClaudication incalfFemoral pulse felt but distal pulses absent Distal obstructionAnkle pulses absentClaudication incalf and footFemoral and popliteal pulses palpable

Answer: C. Insulinoma

The most common neuroendocrine tumor of the pancreas is insulinoma (4 per million). Insulinoma is an insulin-producing tumor of the pancreas, with more than 90% of them beingbenign. It occurs in >40 years in patients without MEN 1 syndrome and <40 years in patientswith MEN 1. It presents with symptoms of hypoglycemia such as weakness, headaches, sweating,faintness, seizures, and altered behavior. These occur after fasting or exertion and improve afterglucose intake. The investigation of choice for insulinoma is the determination of 72-hour fastingglucose and serum insulin levels. C-peptide and proinsulin levels are also elevated. Medical management includes: • Frequent carbohydrate-rich meals • Somatostatin analogs like octreotide are effective in controlling symptoms due to excess insulinsecretion. They should be used with caution as they can suppress counterregulatory hormones,such as growth hormone (GH), glucagon, and catecholamines, and precipitously worsenhypoglycemia. • Diazoxide can be used in the initial management of insulinoma as it inhibits insulin release. Itsside effects include sodium retention and nausea. • Everolimus has been found to be highly effective in improving glycemic control in patients withinsulinoma owing to its antitumor effect and induction of insulin resistance. Enucleation and pancreatectomy are the definitive surgical management of insulinoma. Other options: Option A: Gastrinoma has an incidence of 0.5 to 4 in a million. Options B & D: Somatostatinoma and VIPoma are much rarer than gastrinoma.