UPSC-CMS 2019 Practice Questions

Q: A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:

Pancoast lung. ***Pancoast lung*** - A **Pancoast tumor** (superior sulcus tumor) is a **non-small cell lung cancer** located at the apex of the lung, typically invading adjacent structures. - This invasion can lead to **Pancoast syndrome**, characterized by **shoulder and arm pain** (due to brachial plexus involvement) and **Horner's syndrome** (ptosis, miosis, anhidrosis due to sympathetic chain involvement), often accompanied by rib erosion [1]. *Bronchial carcinoma* - While a Pancoast tumor is a type of **bronchial carcinoma** (lung cancer), this option is too general and doesn't specify the unique apical location and associated neurological symptoms [1]. - Bronchial carcinomas can present with a wide range of symptoms, including cough, hemoptysis, and weight loss, but the specific triad of symptoms described points to a particular subtype. *Lung abscess* - A **lung abscess** is a pus-filled cavity in the lung, usually caused by bacterial infection, and typically presents with fever, cough with purulent sputum, and sometimes pleuritic chest pain. - It does not typically cause **arm pain**, **ptosis**, or **rib erosion** unless there is direct extension from the abscess, which is uncommon and not the primary presentation. *Adenocarcinoma of lung* - **Adenocarcinoma** is a subtype of **non-small cell lung cancer**, but it is generally located in the periphery of the lung and is less likely to present with the classic **Pancoast syndrome** symptoms [1]. - While it can be found in the apex, the specific clinical presentation (arm pain, ptosis, rib erosion) points more strongly to the syndrome that results from apical tumor location rather than just the histological type.

Q: The most common organism causing Acute Otitis media in children is:

Streptococcus pneumoniae. ***Streptococcus pneumoniae*** - **_Streptococcus pneumoniae_** is the most frequent bacterial cause of **acute otitis media (AOM)** in children, accounting for a significant percentage of cases. - Its presence often leads to **inflammation** and **fluid accumulation** in the middle ear, characteristic of AOM. *Staphylococcus epidermidis* - While **_Staphylococcus epidermidis_** is a common **skin commensal** and a frequent cause of device-related infections, it is rarely implicated in acute otitis media. - Its role in AOM is usually limited to **contaminant cultures** rather than true infection. *Klebsiella pneumoniae* - **_Klebsiella pneumoniae_** is more commonly associated with **pneumonia**, **urinary tract infections**, and **healthcare-associated infections**, particularly in immunocompromised individuals. - It is an **uncommon cause** of typical acute otitis media in healthy children. *Escherichia coli* - **_Escherichia coli_** is a common cause of **urinary tract infections** and **gastrointestinal infections**. - It is **rarely a primary cause** of acute otitis media, especially in otherwise healthy children, unless there are underlying risk factors or specific infection pathways.

Q: In diffuse axonal injury all are true EXCEPT:

CT scan shows pathognomonic finding. ***CT scan shows pathognomonic finding*** - While CT scans can sometimes show petechial hemorrhages or small white matter lesions in **diffuse axonal injury (DAI)**, these findings are **not pathognomonic** and can be absent even in severe cases. - **MRI** is more sensitive for detecting microhemorrhages and white matter changes, but even MRI findings are not always definitively diagnostic of DAI, especially in milder forms. - CT scan has **low sensitivity** for DAI, often appearing normal or showing only subtle findings. *Usually causes prolonged coma* - **Diffuse axonal injury (DAI)** is a common cause of **prolonged coma** after traumatic brain injury, as widespread shearing forces disrupt neuronal connections [1]. - The severity and duration of coma correlate with the extent of axonal damage, with severe DAI typically resulting in immediate and prolonged loss of consciousness. *Seen in high energy* - DAI typically results from **high-energy acceleration-deceleration forces**, often seen in motor vehicle accidents or falls from significant heights [1]. - These forces cause differential movement between various parts of the brain, leading to **shearing and stretching of axons** [1]. *Form of primary brain injury* - DAI is considered a **primary brain injury** because the axonal damage occurs at the **moment of impact** due to mechanical forces [1]. - This contrasts with secondary brain injuries, which develop over time due to complications like edema or ischemia. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1262-1264.

Q: A 20 years old man had history of pain in the right side of abdomen. His X-ray abdomen AP view shows radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:

Renal Calculus. ***Renal Calculus*** - A **radio-opaque shadow** in the right abdomen, located **behind the vertebral column** on a lateral X-ray, is highly suggestive of a **renal calculus (kidney stone)**. - Renal calculi are located in the **retroperitoneal space**. On a lateral X-ray view, retroperitoneal structures like the kidneys appear to be **superimposed over or behind the vertebral column**, which is the key anatomical landmark for localization. - The clinical presentation of right-sided abdominal pain combined with this radiological finding makes renal calculus the most probable diagnosis. *Gall stone disease* - **Gallstones** are typically located in the **right upper quadrant** of the abdomen on an AP view but would appear **anterior to the vertebral column** on a lateral X-ray, as the gallbladder is an intraperitoneal organ. - Only about 10-20% of gallstones are sufficiently **calcified** to be radio-opaque on plain X-ray. *Phlebolith* - **Phleboliths** are calcified venous thrombi, commonly found in the **pelvis** and would appear within the **vascular structures**, not typically behind the vertebral column in the mid-abdomen in a pattern consistent with a renal calculus. - While they are radio-opaque, their usual anatomical location and characteristic **central lucency** (target sign) help differentiate them. *Calcified mesenteric lymph node* - **Calcified mesenteric lymph nodes** are common incidental findings and would be located within the **mesentery**, appearing **anterior to the vertebral column** on a lateral X-ray. - They often have an irregular or lobulated appearance, distinct from the more discrete and often smoother shape of a renal calculus.

Q: Ventral hernia includes all EXCEPT:

Inguinal hernia. ***Inguinal hernia*** - An **inguinal hernia** is a protrusion of abdominal contents through the **inguinal canal**, located in the groin region. - It is **NOT a ventral hernia** because it occurs through the inguinal canal in the groin, not through the anterior abdominal wall directly. - Inguinal hernias are classified separately as **groin hernias**, distinct from ventral hernias. *Umbilical hernia* - An **umbilical hernia** occurs through a defect in the **umbilical ring** at the umbilicus. - This is a **true ventral hernia** as it protrudes directly through the anterior abdominal wall at the umbilicus. - Common in infants and adults, especially in conditions that increase intra-abdominal pressure. *Epigastric hernia* - An **epigastric hernia** involves protrusion of preperitoneal fat or peritoneum through a defect in the **linea alba** between the xiphoid process and the umbilicus. - This is a **ventral hernia** because it occurs directly in the anterior abdominal wall through the midline. *Para-umbilical hernia* - A **para-umbilical hernia** occurs through a defect in the **linea alba** adjacent to, but not directly through, the umbilical cicatrix. - This is classified as a **ventral hernia** due to its location in the anterior abdominal wall near the umbilicus.

Q: Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:

Diagnostic laparoscopy. ***Diagnostic laparoscopy*** - **Diagnostic laparoscopy** is the **most sensitive and specific method** for detecting diaphragmatic injuries, especially when initial imaging like X-ray is normal but suspicion remains high after blunt trauma. - It allows **direct visualization** of the diaphragm for tears, herniation of abdominal contents, and associated visceral injuries, enabling simultaneous repair. *CECT abdomen* - While a **CECT abdomen** can show some diaphragmatic injuries, its sensitivity is **limited, especially for small tears**. - It may identify associated organ damage but might miss non-displaced diaphragmatic ruptures, particularly in the acute phase. *Diagnostic peritoneal lavage and proceed* - **Diagnostic peritoneal lavage (DPL)** is primarily used to detect intra-abdominal hemorrhage or viscus perforation, not specifically diaphragmatic injury. - A positive DPL (indicating bleeding) does not directly localize diaphragmatic trauma. *Upper GI contrast study* - An **Upper GI contrast study** is useful for diagnosing a **herniated stomach or small bowel** into the thoracic cavity in chronic or delayed presentations of diaphragmatic injury. - It is **less effective for acute detection** of diaphragmatic tears without significant herniation and does not allow for direct visualization or repair.

Q: Urinary bladder can be injured in all of the following operations EXCEPT:

Inguinal hernia repair. ***Inguinal hernia repair*** - While theoretically possible, bladder injury during **inguinal hernia repair** is exceedingly rare, often less than 1% as the bladder is not typically in the direct field of dissection. - The surgical approach for inguinal hernias generally involves layers superficial to the bladder, making direct injury much less common than in pelvic surgeries. - Rare cases occur with **sliding hernias** where the bladder may form part of the hernia sac wall. *Surgery for rectum* - **Anterior resection of the rectum** or abdominoperineal resection involves dissecting close to the bladder's posterior and inferior aspects, particularly the **bladder base** and **ureteral entries**. - Procedures like low anterior resection for rectal cancer pose a significant risk due to the **proximity of the bladder** to the surgical field in the pelvis. *Inguinal lymph node dissection* - **Inguinal lymph node dissection** is primarily a superficial groin procedure involving removal of superficial and deep inguinal nodes. - While bladder injury is **theoretically possible** if dissection extends unusually deep or medially toward the retropubic space, this is **extremely rare** in standard practice. - The risk is significantly lower than pelvic operations but higher than standard inguinal hernia repair due to the extent of dissection. *Hysterectomy* - During a **hysterectomy** (removal of the uterus), the bladder lies anterior and inferior to the uterus and cervix, making it highly susceptible to injury. - The dissection planes for detaching the bladder from the lower uterine segment and cervix pose a substantial risk, especially during **total abdominal hysterectomy** or **vaginal hysterectomy**. - This is one of the **most common** causes of iatrogenic bladder injury.

Q: A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Chronic subdural haematoma. ***Chronic subdural haematoma*** - This diagnosis fits the clinical picture of a **minor head injury** followed by a **delayed** presentation (one month later) of **slowly developing neurological signs** and headache, especially in an **elderly patient on anticoagulants**. - **Anticoagulation** increases the risk for bleeding, and the elderly are more susceptible due to brain atrophy, which stretches and makes bridging veins more vulnerable to tearing from minor trauma. *Acute subdural haematoma* - An acute subdural haematoma typically presents within **72 hours** of the initial trauma, with **rapidly progressive neurological deficits**, unlike the delayed and gradual onset described. - While anticoagulation increases risk, the **timeframe** of symptom onset is inconsistent with an acute presentation. *Extradural haematoma* - Extradural haematomas are usually associated with a **lucid interval** followed by rapid deterioration due to arterial bleeding, often from the **middle meningeal artery**, and rarely occur in the elderly or from minor trauma. - It would present much **sooner** after the injury, typically within hours, and is less common in this age group without significant impact. *Subarachnoid haemorrhage* - Subarachnoid haemorrhage typically presents with a **sudden onset**, **"thunderclap" headache**, often described as the "worst headache of my life," and is not typically associated with a minor head injury followed by a delayed, slowly progressive course. - While anticoagulants could worsen bleeding, the **temporal profile** and **gradual neurological decline** are not characteristic of a subarachnoid haemorrhage.

Q: Which of the following is NOT true about Dupuytren's Contracture?

Not familial. ***Not familial*** - This is the **CORRECT answer** because this statement is **FALSE** - Dupuytren's contracture **IS familial** and has a strong genetic predisposition. - The condition often runs in families, exhibiting an **autosomal dominant inheritance pattern**. - Its familial nature is a well-established risk factor, making "not familial" the incorrect statement about Dupuytren's contracture. *Autosomal dominant* - This statement is **TRUE** about Dupuytren's contracture, which is frequently inherited in an **autosomal dominant pattern**. - A single copy of an altered gene is sufficient to cause the condition. - This genetic link explains why it often runs in families and is more prevalent in certain populations (especially Northern Europeans). *Associated with alcoholism, smoking and hypothyroidism* - This statement is **TRUE**; Dupuytren's contracture has known associations with several risk factors including **alcoholism**, **smoking**, and **hypothyroidism**. - Other risk factors include diabetes mellitus and epilepsy. - These conditions are thought to influence cellular processes that contribute to the proliferation of fibroblasts and collagen deposition in the palmar fascia. *Occurs in elderly men* - This statement is **TRUE**; Dupuytren's contracture is more common in **males** and typically presents in **middle-aged to elderly individuals**. - While it can occur in women, it is more prevalent (male:female ratio ~7:1) and often more severe in men. - Peak incidence is in the 5th to 7th decades of life.

Question 1

Regarding "Quinsy" all of the following are correct EXCEPT:

Accepted Answer

Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic

Answer

It is an abscess in the peritonsillar region

Answer

In early stage, intravenous broad spectrum antibiotics may resolve it

Answer

Severe trismus is caused by spasm induced by pterygoid muscles

Question 2

A 50 year old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with the erosion of the adjacent rib. The probable diagnosis is:

Accepted Answer

Pancoast lung

Answer

Bronchial carcinoma

Answer

Lung abscess

Answer

Adenocarcinoma of lung

Question 3

The most common organism causing Acute Otitis media in children is:

Accepted Answer

Streptococcus pneumoniae

Answer

Staphylococcus epidermidis

Answer

Klebsiella pneumoniae

Answer

Escherichia coli

Question 4

In diffuse axonal injury all are true EXCEPT:

Accepted Answer

CT scan shows pathognomonic finding

Answer

Seen in high energy

Answer

Form of primary brain injury

Answer

Usually causes prolonged coma

Question 5

A 20 years old man had history of pain in the right side of abdomen. His X-ray abdomen AP view shows radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:

Accepted Answer

Renal Calculus

Answer

Gall stone disease

Answer

Phlebolith

Answer

Calcified mesenteric lymph node

Question 6

Ventral hernia includes all EXCEPT:

Accepted Answer

Inguinal hernia

Answer

Umbilical hernia

Answer

Epigastric hernia

Answer

Para-umbilical hernia

Question 7

Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:

Accepted Answer

Diagnostic laparoscopy

Answer

CECT abdomen

Answer

Diagnostic peritoneal lavage and proceed

Answer

Upper GI contrast study

Question 8

Urinary bladder can be injured in all of the following operations EXCEPT:

Accepted Answer

Inguinal hernia repair

Answer

Surgery for rectum

Answer

Inguinal lymph node dissection

Answer

Hysterectomy

Question 9

A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Accepted Answer

Chronic subdural haematoma

Answer

Acute subdural haematoma

Answer

Extradural haematoma

Answer

Subarachnoid haemorrhage

Question 10

Which of the following is NOT true about Dupuytren's Contracture?

Accepted Answer

Not familial

Answer

Autosomal dominant

Answer

Associated with alcoholism, smoking and hypothyroidism

Answer

Occurs in elderly men

UPSC-CMS 2019

ENT

Internal Medicine

Microbiology

Pathology

Radiology

Surgery