UPSC-CMS 2013 Practice Questions

Q: Primary hyper-aldosteronism presents with all of the following except :

Hyperkalemia. ***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].

Q: 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 ?

1, 3 and 4 only. ***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.

Q: Carcinoma of pyriform fossa usually presents with :

Dysphagia. ***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.

Q: The nerve most likely to get injured in patients with fracture of upper end of radius is :

Posterior interosseous. ***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.

Q: Pancreatic calculi are composed of :

Calcium carbonate. ***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.

Q: The 'claw sign' in barium enema study favours the diagnosis of :

Intussusception. ***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.

Q: 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:

Endoscopic stenting of bile duct. **_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.

Q: The treatment of choice for congenital hypertrophic pyloric stenosis is :

Ramstedt's operation. ***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.

Question 1

Primary hyper-aldosteronism presents with all of the following except :

Accepted Answer

Hyperkalemia

Answer

Hypertension

Answer

Frontal headache

Answer

Periodic paralysis

Question 2

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 ?

Accepted Answer

1, 3 and 4 only

Answer

2, 3 and 4 only

Answer

1, 2 and 3 only

Answer

1, 2, 3 and 4

Question 3

Carcinoma of pyriform fossa usually presents with :

Accepted Answer

Dysphagia

Answer

Lump in the neck

Answer

Cough

Answer

Hoarseness

Question 4

The nerve most likely to get injured in patients with fracture of upper end of radius is :

Accepted Answer

Posterior interosseous

Answer

Ulnar

Answer

Median

Answer

Radial

Question 5

Pancreatic calculi are composed of :

Accepted Answer

Calcium carbonate

Answer

Calcium phosphate

Answer

Calcium oxalate

Answer

Calcium bilirubinate

Question 6

The 'claw sign' in barium enema study favours the diagnosis of :

Accepted Answer

Intussusception

Answer

Sigmoid volvulus

Answer

Crohn's disease

Answer

Gastro colic fistula

Question 7

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:

Accepted Answer

Endoscopic stenting of bile duct

Answer

Total pancreatectomy

Answer

Biliary and gastric bypass

Answer

Pancreaticoduodenectomy (Whipple procedure)

Question 8

Laparoscopic instruments are best sterilized by :

Accepted Answer

Autoclaving

Answer

Ethylene oxide

Answer

Hot air oven

Answer

2% Glutaraldehyde

Question 9

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 ?

Accepted Answer

Splenic rupture

Answer

Cardiac tamponade

Answer

Rupture left lobe of liver

Answer

Intestinal perforation

Question 10

The treatment of choice for congenital hypertrophic pyloric stenosis is :

Accepted Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Heller's operation

Answer

Gastrojejunostomy

UPSC-CMS 2013

Internal Medicine

Orthopaedics

Pathology

Radiology

Surgery