Internal Medicine
3 questionsPrimary hyper-aldosteronism presents with all of the following except :
Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?
Carcinoma of pyriform fossa usually presents with :
UPSC-CMS 2013 - Internal Medicine UPSC-CMS Practice Questions and MCQs
Question 21: Primary hyper-aldosteronism presents with all of the following except :
- A. Hyperkalemia (Correct Answer)
- B. Hypertension
- C. Frontal headache
- D. Periodic paralysis
Explanation: ***Hyperkalemia*** - Primary hyperaldosteronism is characterized by **excessive aldosterone secretion**, which promotes sodium reabsorption and potassium excretion in the renal tubules [1]. - Therefore, patients typically present with **hypokalemia**, not hyperkalemia, due to increased urinary potassium loss [1]. *Hypertension* - **Elevated aldosterone** leads to increased **sodium reabsorption** and water retention, resulting in expanded extracellular fluid volume and **hypertension** [2]. - This is a hallmark clinical feature of primary hyperaldosteronism, often severe and resistant to conventional therapy. *Frontal headache* - **Hypertension**, a common manifestation of primary hyperaldosteronism, can cause various symptoms, including **headaches**, which can be frontal. - While not specific to hyperaldosteronism, it is a frequent symptom secondary to the elevated blood pressure. *Periodic paralysis* - **Severe hypokalemia**, a characteristic feature of primary hyperaldosteronism, can lead to muscle weakness and **periodic paralysis** [3]. - This occurs because potassium is essential for normal muscle function, and its depletion impairs nerve and muscle excitability [3].
Question 22: Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?
- A. 2, 3 and 4 only
- B. 1, 2 and 3 only
- C. 1, 3 and 4 only (Correct Answer)
- D. 1, 2, 3 and 4
Explanation: ***1, 3 and 4 only*** - **Parenteral nutrition (PN)** is used when the gastrointestinal tract is non-functional or inaccessible, making **enteral nutrition (EN)** impossible or inadequate. - **Hyperglycemia** is a common complication due to the high glucose content in PN solutions, and **liver function abnormalities** (e.g., cholestasis, steatosis) can develop with prolonged use. *2, 3 and 4 only* - This option incorrectly states that the parenteral route is better than the enteral route. **Enteral nutrition** is generally preferred due to being more physiological, safer, and less expensive [1]. - While hyperglycemia and liver dysfunction are correct complications, the assertion about the superiority of the parenteral route is false. *1, 2 and 3 only* - This option incorrectly claims that **parenteral nutrition** is a better choice than the enteral route (statement 2). **Enteral nutrition** is always the preferred route if the gut works [1]. - It also omits **hyperglycemia**, which is a frequent and significant complication of parenteral nutrition. *1, 2, 3 and 4* - This option incorrectly includes statement 2, which suggests the parenteral route is superior to the enteral route. **Enteral nutrition** is always preferred when feasible [1]. - While statements 1, 3, and 4 are correct, the inclusion of statement 2 makes this option incorrect.
Question 23: Carcinoma of pyriform fossa usually presents with :
- A. Lump in the neck
- B. Cough
- C. Dysphagia (Correct Answer)
- D. Hoarseness
Explanation: ***Dysphagia*** - Carcinoma of the **pyriform fossa** is a type of hypopharyngeal cancer, and given its anatomical location, it commonly interferes with swallowing [1]. - The pyriform fossa lies immediately lateral to the laryngeal inlet, and involvement here directly impacts the ability to form a **food bolus** and propel it into the esophagus. *Lump in the neck* - A neck lump can occur, especially if there is **lymph node metastasis**, but it's often a later symptom [1]. - **Dysphagia** usually precedes the development of a palpable neck mass as the primary tumor expands within the pyriform fossa [1]. *Cough* - While aspiration might lead to coughing, it's not the primary presenting symptom. - Cough is more commonly associated with laryngeal involvement or **tracheal invasion**, which can occur with advanced disease. *Hoarseness* - **Hoarseness** is a prominent symptom if the **vocal cords** or recurrent laryngeal nerve are directly involved [2]. - The pyriform fossa is adjacent but distinct from the vocal cords, so hoarseness is not typically the initial or most common symptom unless the tumor extends medially.
Orthopaedics
1 questionsThe nerve most likely to get injured in patients with fracture of upper end of radius is :
UPSC-CMS 2013 - Orthopaedics UPSC-CMS Practice Questions and MCQs
Question 21: The nerve most likely to get injured in patients with fracture of upper end of radius is :
- A. Ulnar
- B. Posterior interosseous (Correct Answer)
- C. Median
- D. Radial
Explanation: ***Posterior interosseous*** - The **posterior interosseous nerve** (deep branch of radial nerve) winds around the **neck of radius** through the **radial tunnel** between the heads of the supinator muscle, making it most vulnerable to injury with upper radial fractures. - Injury results in weakness of **finger and thumb extensors** with no sensory loss, as it is a purely **motor nerve** branch. *Ulnar* - The **ulnar nerve** passes behind the **medial epicondyle** of the humerus, making it vulnerable to elbow injuries but not typically affected by upper radial fractures. - Injury leads to **claw hand deformity** and sensory loss in the **medial hand**, which is anatomically distant from the radius. *Median* - The **median nerve** travels through the **cubital fossa** and is anatomically protected from direct trauma by upper radial fractures. - More commonly injured by **distal radial fractures** (Colles' fracture) causing **carpal tunnel compression**, not upper end fractures. *Radial* - The **radial nerve trunk** courses around the **spiral groove** of the humerus, making it susceptible to **humeral shaft fractures**, not upper radial fractures. - Injury causes **wrist drop** and sensory loss over the **posterior forearm**, but the main trunk is anatomically distant from the upper radius.
Pathology
1 questionsPancreatic calculi are composed of :
UPSC-CMS 2013 - Pathology UPSC-CMS Practice Questions and MCQs
Question 21: Pancreatic calculi are composed of :
- A. Calcium carbonate (Correct Answer)
- B. Calcium phosphate
- C. Calcium oxalate
- D. Calcium bilirubinate
Explanation: ***Calcium carbonate*** - Pancreatic calculi are predominantly composed of **calcium carbonate (70-90%)**, which precipitates around a protein-rich nidus [1]. - This occurs in **chronic calcific pancreatitis**, where altered pancreatic juice composition leads to calcium salt precipitation and stone formation [1], [2]. - The stones are radiopaque and can be seen on plain radiography, helping in diagnosis. *Calcium phosphate* - While **calcium phosphate** may be present in small amounts in pancreatic stones, it is **not the primary component**. - Calcium phosphate is more commonly associated with certain types of urinary calculi. *Calcium oxalate* - **Calcium oxalate** is the most common component of **renal (kidney) stones**, not pancreatic stones. - Kidney stone formation is influenced by factors like dietary oxalate, hydration status, and urinary pH, distinct from pancreatic pathophysiology. *Calcium bilirubinate* - **Calcium bilirubinate** is a major component of **pigment gallstones**, particularly black pigment stones formed in the gallbladder. - These stones are associated with conditions like chronic hemolysis, cirrhosis, or biliary infections, and are entirely distinct from pancreatic calculi. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 407-408. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 893-895.
Radiology
1 questionsThe 'claw sign' in barium enema study favours the diagnosis of :
UPSC-CMS 2013 - Radiology UPSC-CMS Practice Questions and MCQs
Question 21: The 'claw sign' in barium enema study favours the diagnosis of :
- A. Sigmoid volvulus
- B. Crohn's disease
- C. Gastro colic fistula
- D. Intussusception (Correct Answer)
Explanation: ***Intussusception*** - The **"claw sign"**, or sometimes called the **"crescent sign"** or **"meniscus sign,"** on a barium enema is indicative of intussusception, where the contrast material fills the space between the intussusceptum and intussuscipiens, creating a claw-like appearance. - This sign represents the barium outlining the leading edge of the **intussusceptum** as it telescopes into the more distal bowel. *Sigmoid volvulus* - Sigmoid volvulus typically presents with a **"coffee bean sign"** or **"omega loop sign"** on plain abdominal radiographs due to the massively dilated, air-filled sigmoid colon. - Barium enema in sigmoid volvulus would show a **"bird's beak"** or **"ace of spades"** appearance at the site of the twist, representing the tapered narrowing. *Crohn's disease* - Crohn's disease is characterized by various findings on barium studies, such as **"skip lesions,"** **cobblestoning**, and **ulcerations**, but not a claw sign. - Strictures, fistulas, and thickened bowel walls are also common in Crohn's disease, creating different radiological patterns. *Gastro colic fistula* - A gastrocolic fistula is an abnormal connection between the stomach and the colon, most commonly seen in advanced gastric carcinoma or Crohn's disease. - On barium enema or upper GI series, it would be identified by the direct visualization of contrast flowing from the colon into the stomach or vice versa, not by a claw sign.
Surgery
4 questionsA 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:
Laparoscopic instruments are best sterilized by :
A 32 year-old male patient presents in casualty department with history of RTA one hour back; on examination is found that BP is 90/50 mm Hg, pulse rate 110 beats per minute, with fracture left lower ribs, and generalized distension of abdomen with guarding and rigidity. He also complained of pain on the tip of the left shoulder. As a casualty Medical Officer you must exclude which one of the following clinical conditions on the primary basis ?
The treatment of choice for congenital hypertrophic pyloric stenosis is :
UPSC-CMS 2013 - Surgery UPSC-CMS Practice Questions and MCQs
Question 21: A 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:
- A. Total pancreatectomy
- B. Biliary and gastric bypass
- C. Pancreaticoduodenectomy (Whipple procedure)
- D. Endoscopic stenting of bile duct (Correct Answer)
Explanation: **_Endoscopic stenting of bile duct_** - The presence of **distant liver metastases** and **vascular encasement** makes the disease inoperable and renders curative surgery impossible. - **Endoscopic stenting** offers effective palliation for **obstructive jaundice**, improving quality of life by relieving symptoms such as itching and nausea, and preventing cholangitis. *Total pancreatectomy* - This is an **extensive surgical procedure** suitable for resectable pancreatic head tumors without metastatic disease. - It is **highly morbid** and not indicated in the presence of **liver metastases** and **vascular encasement**, as it would not be curative and carries significant risks. *Biliary and gastric bypass* - This procedure aims to relieve both **biliary obstruction** and potential gastric outlet obstruction, which can occur from pancreatic head tumors. - While it addresses symptoms, it is still a **surgical intervention** with associated risks and is generally reserved for patients with a longer life expectancy or when endoscopic stenting is unsuccessful or unfeasible. It is not the most appropriate initial palliative step given the metastatic disease. *Pancreaticoduodenectomy (Whipple procedure)* - The **Whipple procedure** is the standard curative surgical treatment for **resectable pancreatic head cancers**. - However, the patient's presentation with **liver metastases** and **gastroduodenal artery encasement** indicates unresectable disease, making this procedure inappropriate and potentially harmful.
Question 22: Laparoscopic instruments are best sterilized by :
- A. Autoclaving (Correct Answer)
- B. Ethylene oxide
- C. Hot air oven
- D. 2% Glutaraldehyde
Explanation: ***Autoclaving*** - **Autoclaving** remains the gold standard for sterilizing **heat-stable** laparoscopic instruments (e.g., reusable trocars, simple graspers, scissors without delicate components). - Uses **moist heat** (steam at 121-134°C under pressure) to kill all microorganisms including spores, achieving complete sterilization. - **Advantages**: Rapid cycle time (15-30 minutes), cost-effective, no toxic residues, widely available. - **Limitation**: Many modern laparoscopic instruments contain heat-sensitive components (fiber optic cables, cameras, delicate optics) that may be damaged by repeated autoclaving. *Ethylene oxide* - **Ethylene oxide (EtO)** is the preferred method for **heat-sensitive** laparoscopic equipment including telescopes, cameras, and instruments with complex electronics. - Provides complete sterilization at low temperatures (37-63°C), making it ideal for delicate optics and plastics. - **Disadvantages**: Requires 8-12 hours for aeration to remove toxic residues, is a known **carcinogen**, needs special facilities and ventilation, and has longer cycle times (12-24 hours total). *Hot air oven* - Uses **dry heat** (160-180°C for 1-2 hours) suitable for glassware, oils, and powders. - **Not suitable** for laparoscopic instruments due to high temperatures damaging plastics, rubber, and optical components, and poor penetration into lumens. - Less efficient than moist heat sterilization. *2% Glutaraldehyde* - **2% Glutaraldehyde** provides **high-level disinfection** (20-30 minutes) or sterilization (10 hours contact time) for heat-sensitive instruments. - Commonly used for routine processing of laparoscopic equipment between cases when full sterilization is not required. - **Disadvantages**: Prolonged immersion time needed for sterilization, toxic fumes requiring ventilation, does not kill all spores reliably in short contact times, and is primarily a disinfectant rather than a practical sterilant. **Note**: Modern practice increasingly uses low-temperature sterilization methods (hydrogen peroxide plasma, peracetic acid systems) for heat-sensitive laparoscopic equipment, combining the benefits of complete sterilization with protection of delicate instruments.
Question 23: A 32 year-old male patient presents in casualty department with history of RTA one hour back; on examination is found that BP is 90/50 mm Hg, pulse rate 110 beats per minute, with fracture left lower ribs, and generalized distension of abdomen with guarding and rigidity. He also complained of pain on the tip of the left shoulder. As a casualty Medical Officer you must exclude which one of the following clinical conditions on the primary basis ?
- A. Splenic rupture (Correct Answer)
- B. Cardiac tamponade
- C. Rupture left lobe of liver
- D. Intestinal perforation
Explanation: ***Splenic rupture*** - **Kehr's sign** (pain on the tip of the left shoulder) is **pathognomonic** for splenic injury, indicating diaphragmatic irritation from blood in the peritoneal cavity - **Left lower rib fractures** (ribs 9-12) are **classically associated** with splenic injury in blunt abdominal trauma - The combination of **hypotension** (90/50 mmHg), **tachycardia** (110 bpm), **abdominal distension with guarding and rigidity** indicates **hemoperitoneum** from active bleeding - This is a **life-threatening surgical emergency** requiring immediate exclusion and intervention (FAST scan/DPL, possible laparotomy) - Among all options, splenic rupture **best fits the entire clinical picture** and requires primary exclusion *Cardiac tamponade* - While cardiac tamponade is life-threatening, the clinical presentation **does not support** this diagnosis - **No Beck's triad** features mentioned (hypotension, jugular venous distension, muffled heart sounds) - Left lower rib fractures are **below the heart level** and primarily associated with **splenic or renal injury** - **Kehr's sign specifically indicates diaphragmatic irritation**, pointing to intra-abdominal rather than pericardial pathology - The predominant findings are **abdominal**, not thoracic *Rupture left lobe of liver* - Left lobe liver injury could cause hypotension and abdominal signs - However, **left lower rib fractures** more commonly injure the **spleen** rather than the left lobe of liver - **Kehr's sign is more specific for splenic injury** than hepatic injury - Right-sided rib fractures and right shoulder pain would be more suggestive of liver injury *Intestinal perforation* - Intestinal perforation causes **peritonitis** with guarding and rigidity - However, peritonitis typically develops over **hours**, not within 1 hour of trauma - **Hypotension and tachycardia** in the acute phase are more consistent with **hemorrhage** than peritonitis - **Kehr's sign is NOT a feature** of intestinal perforation - This would be a secondary concern after excluding hemorrhagic causes
Question 24: The treatment of choice for congenital hypertrophic pyloric stenosis is :
- A. Duodenojejunostomy
- B. Heller's operation
- C. Ramstedt's operation (Correct Answer)
- D. Gastrojejunostomy
Explanation: ***Ramsted's operation*** - **Ramstedt pyloromyotomy** is the definitive surgical treatment for **congenital hypertrophic pyloric stenosis**. - This procedure involves a longitudinal incision through the serosa and muscular layers of the hypertrophied pylorus, stopping short of the mucosa, to relieve the obstruction. *Duodenojejunostomy* - This procedure involves connecting the **duodenum to the jejunum**, typically performed to bypass an obstruction or resection in the distal duodenum or pancreas. - It is not indicated for **pyloric stenosis**, which is an obstruction at the gastric outlet. *Heller's operation* - Also known as **Heller myotomy**, this procedure is used to treat **achalasia**, a disorder affecting the esophagus. - It involves cutting the muscle fibers of the lower esophageal sphincter to facilitate food passage into the stomach, which is unrelated to **pyloric hypertrophy**. *Gastrojejunostomy* - This surgical procedure creates a connection between the **stomach and the jejunum**, bypassing the duodenum. - It is typically performed for conditions like **duodenal obstruction** or distal gastric tumors, not for primary pyloric muscle hypertrophy.