MCI 08 sept

1. Marcus Gunn pupil seen in?
a. Neurosyphilis
b. Diabetes mellitus
c. Multiple sclerosis
d. Gullian barre syndrome.

Explanation: answer is C
Choice C: MARCUS GUNN pupil is weird pupil, which does not have a direct light reflex but has a consensual light reflex. HOW? Read on …………………………
Light reflex has an afferent pathway of optic and efferent pathway through Occulomotor nerve. The afferent info is sent via the lateral geniculate body to the edinger Westphal nucleus located in the midbrain. The basic point to be understood is that the Edinger westphal nucleus has a bilateral discharge i.e. if you shine a torch in lets say left eye of the patient, the left eye of the patient shows pupillary constriction known as DIRECT LIGHT reflex and the opposite eye also shows papillary constriction known as CONSENSUAL light reflex.

Multiple sclerosis as per English language means gliosis at multiple sites in the brain. These sites of gliosis are known as plaques and can be seen in an MRI. The plaques have a propensity to involve the optic pathway, mainly the optic pathway.
Assuming In case only the left optic nerve is affected the DIRECT light reflex on the left side will be afflicted. So the pupil on left side is not constricting. In these circumstances you shall now swing your torchlight to the right side and voila!!!! You manage to stimulate the edinger westphal nucleus, which has a bilateral discharge. You get a direct light reflex in the right eye and a consensual light reflex in the left eye.

Choice A: neurosyphilis has ARGYL ROBERTSON pupil. [Read it as ARP: ACCOMODATION reflex present, PRA – Pupillary reflex absent.]
Choice B: Diabetes mellitus neuropathy can have 3rd nerve palsy with pupillary sparing as per Harrison so light reflex would be preserved.
Choice D: Gullian Barre syndrome is a de-myelinating disorder of the spinal cord presenting with ASCENDING SYMETRICAL FLACCID paralysis. The cranial nerve involved in GBS is the 7th nerve and therefore can be easily excluded.


2. A pregnant woman on phenytoin presents to your clinic, which shall be the best recommendation for her?
a. Continue phenytoin add folic acid
b. Start phenobarbitone
c. Start phenobarbitone and folic acid
d. Start vigarbatrin and folic acid
EXPLANATION: answer is C
Phenytoin causes folic acid deficiency, which is obviously going to cause a dimorophic anemia in the mother. But at the same time the folic acid deficiency has been categorically linked to neural tube defects NTD, the most common being spina bifida occulta.
Hence it is prudent that phenytoin be withdrawn and cover up with phenobarbitone be recommended but with a COVER Of folic acid 0.4mg once a day.

3. Thyrotoxicosis patient presents with palpitations to the OPD. Best immediate management shall be?
a. Propranolol
b. Start propylthiouracil with propranolol
c. Start levothyroxine
d. Start carbimazole with iodine drops
EXPLANATION: ANSWER IS A
Thyroid hormones have a sympathomimetic effect via beta 1 receptors causing palpitations. At the same time they act via beta 2 receptors to cause tremors. Adding fuel to the fire is increased BMR causing heat intolerance.
Since this query does not talk about atrial fibrillation but simple presentation of the patient to the OPD the best answer shall be non selective beta blocker – propranolol.

Choice B would be prudent in case the question talked about a thyroid storm where propyl-thioracil would also prevent formation of T3 form T4
Choice C is used for hypothyroidism
Choice D is used for preoperative management of toxic nodular goiter to prevent the onset of thyroid storm
THYROTOXICOSIS

Primary
Secondary
Cause
L.A.T.S. long acting thyroid stimulator antibody, which mimics TSH.
Remember its different from T.P.O. thyroid peroxidase antibody which is seen in Hashimoto’s Thyroiditis
Pituitary adenoma
Manifestations
Young patient mainly women

Bilateral PROPTOSIS +
MYXEDEMA+
ACROPACHY+


No gender predilection

PROPTOSIS absent
MYXEDEMA absent
ACROPACHY absent
ATRIAL FIBRILLATION present


4. A patient of Tuberculosis present with malaise, fatigue and hyperpigmentation on flexural creases. On lab investigation sodium is 120meq /dl and potassium is 6.5meq/dl. Most probable diagnosis is
a. Addison disease
b. Conn syndrome
c. Secondary Hyperaldosteronism
d. Simmond syndrome
Explanation: Answer is A
Every time you read in any MCQ sodium and potassium values given together the MCQ is obviously gonna talk about aldosterone. The basic action of aldosterone is sodium and water reabsorbtion through the distal tubule and in return gives away potassium. Potassium is precious so after a while the body gives up losing potassium and in turn loses hydrogen ions.

Normal values
Sodium = 135-145meq/dl
Potassium = 3.5-5.5meq/dl
MCQ data states
Hyponatremia
Hyperkalemia

So obviously this MCQ is about hypo aldosteronism. Moreover the cementing point in its favor is hyper pigmentation due to ACTH increase by feedback mechanism.
Tuberculosis dissemination involves various organs incidence wise: peritoneum, genitourinary, Potts spine and adrenal in that order. So in this case TB has spread to the adrenal gland and damaged it causing Addison disease.
Most common cause of ADDISON disease is autoimmunity globally bout in India is TB
The manifestations are weakness due salt wasting, hyper pigmentation, Hyponatremia, Hyperkalemia and metabolic acidosis.
The IOC is ACTH stimulation test that will fail [miserably ………the gland is damaged.]
Drug support would be salt intake to be increased to 8gms /day with FLUDORCORTSIONE which has a high mineralo-corticoid activity.

5. Zollinger Ellison syndrome the best diagnostic protocol:
a. 24 hr basal acid output and maximal acid output.
b. 24 hr secretin study
c. 24 hr gastrin study
d. Histamine stimulation test

6. Bitemporal hemianopia is seen with
a. Pituitary tumor
b. Empty sella syndrome
c. Optic tract damage
d. Occipital cortex damage

7. Definitive diagnosis of phaeochromocytoma?
a. 24 hr urinary catecholamines
b. MIBG Scan
c. CTU
d. Metapyrone test

8. Vessel rupture in hypertension in all parts of the brain except:
a. Temporal lobe
b. Thalamus
c. Cerebrum
d. Putamen
9. Most common cause of mortality after 70 yrs of age?
a. Cardiovascular mortality
b. Diabetes mellitus and complications
c. Peripheral vascular disease
d. Mesenteric insufficiency

10. Which is a pre-cancerous lesion of esophagus
a. barret esophagus
b. x
c. crohn disease
d. Ulcerative colitis

11. Recurrent episodes of Blood stained sputum can be the presenting symptom of?
a. Bronchial adenoma
b. Cavity
c. Bronchiectasis
d. Tuberculosis

12. Lesion of the caudate lobe of basal ganglia causes
a. Chorea
b. atheotosis
c. hemiballismus
d. Intentional tremors

EXPLANATION: The answer is A

Chorea
Atheotosis
Hemiballismus
Lesion of caudate nucleus
Remember the C word
Lesion of putamen
Lesion of subthalaamic nucleus

Involuntary proximal movements eg shrugging of shoulders
Involuntary distal movements eg snake head like movement of hand
Combo of proximal and distal involuntary movements eg involuntary flinging of the arms

Choice D is intentional tremors, which are seen in patients of cerebellar disease.


13. Deficiency of which vitamin does not cause anemia?
a. Biotin
b. Pyridoxine
c. Folic acid
d. B12

14. Punched out lesion in the skull is seen in:
a. Mutiple myeloma
b. Hyperparathyroidism
c. Pagets disease
d. Osteopetrosis


15. Closed Pneumothorax, the best position of the CXR shall be?
a. Expiration in erect position
b. Lateral decubitus position
c. Inspiration in erect position
d. Inspiration in lateral decubitus position.

16. Wide fixed split S2 is seen in:
a. ASD
b. VSD
c. PDA
d. TOF


17. Thrombocytopenia is diagnosed by
a. Bleeding time
b. Clotting time
c. Prothrombin time
d. Activated partial thromboplastin time

18. Extrinsic pathway is measured by
a. BT
b. CT
c. APTT
d. PT

19. Hemophilia pattern of inheritance is:
a. XLR
b. XLD
c. AR
d. AD

20. Digitalis toxicity is managed by:
a. Potassium
b. digiband
c. amiodarone
d. lignocaine

21. Preserved blood does not contain
a. Citrate
b. Heparin
c. Dextrose
d. Phosphate

22. Tumor marker for pancreatic cancer
a. Ca19.9
b. Ca –125
c. BRCA
d. CEA

23. Lumbar puncture needle doesn’t puncture
a. supraspinatus
b. infrspinatus
c. ligamentum flavum
d. x

24. CSF glucose levels are reduced in all of the following except:
a. Bacterial meningitis
b. Viral meningitis
c. Tubercular meningitis
d. Subdural Empyema

25. Diagnostic procedure for kala azar can be which of the following?
a. Indirect fluoroscent antibody test
b. L.D. bodies in splenic aspirate
c. Aldehyde test
d. ELISA

26. Most dangerous toxin is:
a. botulinism
b. x
c. x
d. x
27. NNN media is used for diagnosis of
a. Brucella
b. Leshmania
c. ankylostoma
d. strongyloides stercoralis

28. Young female with complaints of dysnea on exertion and related symptoms of heart etiology. Best modality for investigation shall be:
a. CXR
b. ECG
c. Echocardiography
d. Angiography

29. The following can cause Hypocalcemia
a. calcitonin
b. Hyperparathyroidism
c. Sarcoidosis
d. Lithium therapy

30. The following vitamin is given with vitamin D for osteoporosis
a. Vitamin A
b. Vitamin E
c. Vitamin K
d. Vitamin E

31. Least common fungal infection in immunocompromised hosts shall be:
a. Malazzia furfur
b. Cryptosporidium
c. Candida
d. Penicillium marafucci

Malassezia furfur a lipophilic yeast causes pityriasis versicolor , follicular titriasis, sebborheic dermatitis .

Penicillium marafucci causes hyalohyphomycosis.

32. All are features of hypothyroidism except
a. pretibial myxedema
b. Puffiness of face
c. Low voltage ECG
d. Alopecia and constipation

33. Type 2 diabetes mellitus is caused by:
a. Deficiency of insulin
b. Excess of insulin
c. Resistance to insulin
d. Defective structure of insulin

34. Most common Valvular lesion after MI is seen in:
a. Mitral regurgitation
b. Mitral stenosis
c. Aortic stenosis
d. Aortic regurgitation

35. Auer rods are seen in:
a. ALL
b. AML
c. CML
d. CLL

36. Falciparum malaria causes all except:
a. blackwater fever
b. Algid malaria
c. Hypoglycemia
d. Alkalosis


37. Splenomegaly is not seen in:
a. Sickle cell anemia
b. Gaucher
c. TORCH
d. Kala Azar



38. Bilaterally shrunken kidneys are seen in:
a. Diabetes mellitus
b. Amyloidosis
c. Hydronephrosis
d. Renal vein thrombosis

39. Daily sodium requirement per day would be?
a. 3-5gm
b. 300mg-500mg
c. 3ug- 5ug
d. 3-5mg


40. FTA –ABS is used for diagnosis of
a. Syphilis
b. Borrelia
c. Brucella
d. Lyme disease