Kerala, K Med. CMC Jipmer, St Joh's Medical PG Entrance Test 2015 - 2016

Management of cardiogenic shock
related to acute, severe mitral
regurgitation can include all of the
following EXCEPT:
A. Vasodilation
B. Diuresis
C. Negative inotropy
D. Intra-aortic balloon pump
Answer C.
Medical management of
cardiogenic shock related to acute,
severe MR can include vasodilation
and diuresis as tolerated, positive
inotropic support, and IABP as
needed.

KERALA PG Entrance St Johns, JIPMER , CMC Vellore AIPGMEE 2016

Which of the following is true
regarding cervical trauma?
A The mortality associated with
atlanto-occipital dislocation is 100%.
B Most mortality in cervical trauma is
not the direct result of neural
compression.
C With the advent of CT, no other
imaging is needed for evaluation of the
cervical spine.
D In a neurologically intact patient
with neck pain, the cervical spine can be
cleared immediately with normal
findings on plain cervical radiographs.
E Methylprednisolone should be
started immediately in any trauma patient
suspected of having cervical trauma,
regardless of the findings on neurologic
examination or the time of injury.
Explanation-
Evaluating, treating, or possibly clearing
the cervical spine in a trauma patient is a
procedure that can be complex at times.
In fact, the spine trauma guidelines state
that there is insufficient evidence to even
support treatment guidelines. Initial
immobilization of a trauma victim’s
cervical spine is commonplace with
most emergency medical service
systems. The neck continues to be
immobilized until the spine can be
cleared by clinical assessment or
radiographic imaging. The process of
evaluating begins with a careful history
and physical examination. In the absence
of any suspicious mechanism of injury
and with an asymptomatic patient
(awake, alert, neurologically intact, not
intoxicated, without neck
pain/tenderness, and without other
injuries that prevent appropriate
assessment of the spine or that distract
the patient), imaging is unlikely to be
necessary. However, a symptomatic
patient requires imaging. A three-view
cervical spine series (anteroposterior,
lateral, and odontoid views) is
recommended, sometimes supplemented
by computed tomography to better
define suspicious or poorly visualized
areas on plain cervical radiographs. The
diagnostic performance of helical CT
scanners has a sensitivity approaching
99% and specificity approaching 93%.
Because of this, many trauma centers
have proposed relying exclusively on
CT to evaluate the cervical spine.
However, the CT-generated artifact,
especially in coronal and sagittal
reconstructions, may distort the true
anatomy of the cervical spine.
Nonetheless, missed injuries on CT are
extremely rare and the majority are
ligamentous. In an awake and
neurologically intact patient with neck
pain, three-view plain cervical
radiographs and CT are recommended to
evaluate bony pathology. If pain is still
present despite normal findings on
radiography and CT, either magnetic
resonance imaging or dynamic
flexion/extension films are
recommended. Atlanto-occipital
dislocation, or craniocervical junction
dislocation, occurs in approximately 1%
of patients with cervical spine trauma
and has been noted in 18% to 19% of
patients with fatal cervical spine injuries
at autopsy. Although the entity was
previously perceived as an infrequent
injury resulting in death, improved
emergency management has recently
provided increased survivors. Most
mortality in patients with cervical spine
trauma results from anoxia secondary to
respiratory arrest from other injuries.
The use of steroids, in particular
methylprednisolone, after spinal cord
injury is a matter of great debate. The
original studies performed involved
patients with known neurologic deficits
seen within 8 hours of injury. A 30-
mg/kg bolus, followed by a 23-hour
infusion of 5.4 mg/kg/h, is the usual
protocol. Even in this scenario, the
degree of functional motor improvement
is questionable, and side effects such as
sepsis and pneumonia may occur.
Therefore, no level I evidence exists to
support the use of methylprednisolone
for spinal cord injury, although many
physicians still follow the protocol
based on levels II and III data. However,
in the setting of a neurologically intact
patient or a patient with spinal cord
injury but outside the 8-hour window,
data suggest that steroids should not be
administered.
Answer- B

Hypokalemia

Mild hypokalemia is often without symptoms, although it may cause a small elevation of blood pressure, and can occasionally provoke the development of anabnormal heart rhythm. Severe hypokalemia, with serum potassium concentrations of 2.5–3 meq/l (Nl: 3.5–5.0 meq/l), may cause muscle weakness, myalgia, and muscle cramps (owing to disturbed function of skeletal muscle), and constipation (from disturbed function of smooth muscle). With more severe hypokalemia, flaccid paralysis and hyporeflexia may result. Reports exist of rhabdomyolysis occurring with profound hypokalemia with serum potassium levels less than 2 meq/l. Respiratory depression from severe impairment of skeletal muscle function is found in many patients.

Some electrocardiographic (ECG) findings associated with hypokalemia include flattened or inverted T waves, a U wave, ST depression, and a wide PR interval. Due to prolonged repolarization of ventricular Purkinje fibers, a prominent U wave occurs, frequently superimposed upon the T wave and therefore produces the appearance of a prolonged QT interval.

AIPGMEE 2015

Which one of the following intrinsic hand muscles is
supplied by the median nerve?


Lateral two interossei
Abductor pollicis brevis 
Medial two lumbricales
Flexor pollicis longus
Extensor pollicis

The median nerve supplies the following structures in
the hand:
The abductor pollicis brevis, flexor pollicis brevis,
opponens pollicis
The lateral two lumbricales
The skin of the lateral three and half fingers
The flexor pollicis longus is also supplied by the median
nerve but is not one of the intrinsic hand muscles, being
located in the forearm with its main action being thumb
flexion.
The ulnar nerve supplies all the interossei and the rest
of the hand muscles.

Nystagmus

Opticokinetic nystagmus is a useful test in evaluating the eye
movements of children. A drum or tape with stripes or figures
is slowly rotated or drawn before the child’s eyes in horizontal
and vertical directions. With fixation, the child should visually
track the object in the direction the tape is being drawn, with a
rapid, rhythmic movement (refixation) of the eyes in the
reverse direction to enable fixation on the next figure or stripe.
Absence of such a response may result from failure of fixation,
amaurosis, or disturbed saccadic eye movements.
The child who appears clinically blind because of a conversion
reaction usually exhibits a normal opticokinetic nystagmus
response. Children who manifest congenital nystagmus
and have an opticokinetic nystagmus response in the vertical
plane likely have adequate functional sight. Absence of opticokinetic
nystagmus in the presence of congenital nystagmus
heralds reduced visual acuity. If asymmetry of an opticokinetic
nystagmus response is evident, lateral lesions in the posterior
half of the cerebral hemisphere are likely present. The lesion
is on the side that manifests reduced or absent opticokinetic
nystagmus reactivity. The area of involvement is generally in
the posterotemporal, parietal, or occipital areas. Hemianopic
field defects may exist.
Spontaneous nystagmus (i.e., involuntary oscillatory movements
of the eye) may be horizontal, vertical, or rotary; a patient
can exhibit all three types. The movements may consist of a slow
and a fast phase, giving rise to the termjerk nystagmus.However,
the phases may be of equal duration and amplitude, appearing
pendular.
Nystagmus, especially vertical nystagmus, is most commonly
induced by medications (e.g., barbiturates, phenytoin, carbamazepine,
benzodiazepines). Such nystagmus often has a jerk
component and is usually most prominent in the direction of
gaze. Vertical nystagmus that is not associated with medications
indicates brainstem dysfunction. A few beats of horizontal nystagmus
with extreme lateral gaze are usually normal. Persistent
horizontal nystagmus indicates dysfunction of the cerebellum or
brainstem vestibular systemcomponents; the nystagmus is coarser
(i.e., the amplitude of movements are greater) when the direction
of gaze is toward the side of the lesion. A rare condition, seesaw
nystagmus, is characterized by disconjugate (alternating) movement
of the eyes, which move upward and downward in a seesaw
motion. This type of nystagmus accompanies lesions in the region
of the optic chiasm

AIPGMEE 2015

In which one of the following locations might a
lesion cause a left superior homonymous
quadrantanopia?
a. Frontal lobe
b. Parietal lobe
c. Left eye
d. Temporal lobe
e. None of the above
Answer: d. This visual field loss localizes a lesion in
either the right inferior occipital or right temporal lobe
(see Fig. 12-10). Single ocular lesions do not produce
homonymous defects. When this visual field defect,
which neurologists occasionally label “pie in the sky,”
stems from a temporal lobe lesion, complex partial seizures
may be comorbid.

AIPGMEE 2015

After divorce, children may demonstrate all of the following EXCEPT:

• A feeling of being overburdened by residence in two homes
• Withdrawal
• Indifference at times of reunions
• Academic deterioration
• Expectations that the parents will never get back together

School-aged children may respond with evident depression, may seem indifferent, or may be markedly angry. Other children appear to deny or avoid the issue, behaviorally or verbally. Most children cling to the hope that the actual placement or separation is not real and is only temporary. The child may experience guilt by feeling that the loss, separation, or placement represents rejection and perhaps punishment for misbehavior. Children may protect a parent and assume guilt, believing that their own “badness” caused the parent to depart. (See e16-1.)

AIPGMEE 2015

Which of the following muscles can effectively squeeze urine from the male urethra at the end of micturition?

• Ischiocavernosus muscle
• Bulbospongiosus muscle
• Deep transverse perineal muscle
• Superficial transverse perineal muscle
• Pubococcygeus muscle

The bulbospongiosus muscle covers the bulb of the penis in the superficial perineal space. The urethra, distal to the urethral sphincter, is within the bulb of the penis. Contraction of the muscle squeezes the bulb against the inferior surface of the urogenital diaphragm and thus squeezes the urethra. The ischiocavernosus muscle covers the crus of the penis and squeezes it against the urogenital diaphragm and the ischiopubic ramus. However, because the urethra is not within the crus of the penis, contraction of this muscle has no effect on the urethra. The deep transverse perineal muscle is part of the muscular layer of the urogenital diaphragm but is not in contact with the urethra. The superficial transverse perineal muscle is in the superficial perineal space and does not contact the urethra. The pubococcygeus muscle is part of the muscle layer of the pelvic diaphragm and also does not contact the urethra

AIPGMEE 2015

A T cell undergoing activation has begun to express receptors for IL-2. The IL-2 that will bind to these receptors is produced by:

• T cells
• Natural killer (NK) cells
• Dendritic cells
• Follicular epithelium cells
• Antigen presenting cells

IL-2 is produced by CD4⁺ T cells and, to a lesser degree, by CD8⁺ T cells.

AIPGMEE 2015

A T cell undergoing activation has begun to express receptors for IL-2. The IL-2 that will bind to these receptors is produced by:

• T cells
• Natural killer (NK) cells
• Dendritic cells
• Follicular epithelium cells
• Antigen presenting cells

IL-2 is produced by CD4⁺ T cells and, to a lesser degree, by CD8⁺ T cells.

AIPGMEE 2015

A 13-month old male has decreased numbers of B cells and very low levels of all isotypes of immunoglobulins. This patient would be expected to be unable to clear infections by

• Extracellular bacteria (e.g., Streptococcus spp).
• Intracellular bacteria (e.g., Mycobacterium spp)
• Intracellular protozoa
• Viruses
• Fungi

B cells make antibodies and are the precursors of plasma cells that both synthesize and secrete antibodies. Antibodies are the primary means for inhibiting and killing extracellular bacteria. This patient is likely to have Bruton disease, an agammaglobulinemia that results in increased susceptibility to infection with encapsulated bacteria.

Recommendations for use of antenatal corticosteroids

Recommendations for use of antenatal corticosteroids

The benefits of antenatal administration of corticosteroids to fetuses at risk of preterm delivery vastly outweigh the potential risks. These benefits include not only a reduction in the risk of RDS, but also a substantial reduction in mortality and IVH.

All fetuses between 24 and 34 weeks of gestation at risk of preterm delivery should be considered candidates for antenatal treatment with corticosteroids.

The decision to use antenatal corticosteroids should not be altered by fetal race or gender or by the availability of surfactant replacement therapy.

Patients eligible for therapy with tocolytics should also be eligible for treatment with antenatal corticosteroids.

Treatment consists of either two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses of 6 mg of dexamethasone given intramuscularly 12 hours apart. Optimal benefit begins 24 hours after initiation of therapy and lasts seven days.

Because treatment with corticosteroids for less than 24 hours is still associated with significant reductions in neonatal mortality, RDS, and IVH, antenatal corticosteroids should be given unless immediate delivery is anticipated.

In premature rupture of membranes at less than 30 to 32 weeks of gestation in the absence of clinical chorioamnionitis, antenatal corticosteroid use is recommended because of the high risk of IVH at these early gestational ages.

In complicated pregnancies where delivery prior to 34 weeks of gestation is likely, antenatal corticosteroid use is recommended unless there is evidence that corticosteroids will have an adverse effect on the mother or delivery is imminent.

RDS: respiratory distress syndrome; IVH: intraventricular hemorrhage.

Adapted from: data in the Report of the Consensus Development Conference on the Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes. National Institute of Child Health and Human Development. November 1994. NIH Publication No. 95-3784.
Antenatal Corticosteroids Revisited: Repeat Courses—National Institutes of Health Consensus Development Conference Statement, August 17–18, 2000. Obstet Gynecol 2001; 98:144-150.