The Correct Answer is E

AIDS is difficult to identify serologically in infants because of antibody passed transplacentally from mother to infant. HIV infection itself may not be passed transplacentally, even if the mother is infected. The infant must be observed for as long as 15 months before the presence or absence of HIV infection can be definintively ascertained.

Because of their immune deficits, children with AIDS need to avoid live poliovirus. This virus may be excreted in the stool of immunized children, therefore children living in the same household as children with AIDS should not receive the live poliovirus vaccine.

Diffuse candidiasis appears in children with AIDS because of their poor immune status. Neurologic disease in children with HIV infection may present as progressive encephalopathy. Pneumocystis carinii infection will often recur in previously infected AIDS patients and trimethoprim/sulfamethoxazole is indicated as prophylaxis for this disease.

Ref: Cooper ER, Pelton SI, LeMay M: Acquired immunodeficiency syndrome: A new population of children at risk. Pediatr Clin North Am 1988; 35(6); 1365-1388.

The Correct Answer: B

Diagnosing food allergies in children (and adults) can be a difficult problem. The symptoms are often vague and misinterpreted by parents. The true incidence of food allergies is reported as being very low, somewhere between 1% and 2%. Nuts, especially peanuts, are common causes of food allergy. Infants who develop allergies are often able to tolerate that food again in later life. Skin testing is not accurate; food challenges, under controlled conditions, remain the method of choice for diagnosis. Parents should be taught how to administer epinephrine (Epi Pen Jr.) when their children have severe food allergies and it should be available at home, in the car, and at school.

Ref: Anderson JA: Milk, eggs, and peanuts: Food allergies in children. Am Fam Physician 1997;56(5):1365-1374

ANSWER: D

Most children perceived by their parents to have recurrent infections are, in fact, immuno-competent, generally well, and do not have evidence of chronic illness. These children typically are characterized by normal growth and development, superficial bacterial skin infections and predominantly upper respiratory and occasional lower respiratory tract infections due to common viral and bacterial pathogens. They typically have palpable lymph nodes and normal or enlarged tonsils.

Findings on the history and examination, which would suggest the possibility of immunodeficiency, include the following:

1. Failure to thrive;
2. Severe disease occurring with common viral infections such as chickenpox or measles;
3. More than one serious infection, such as meningitis, pneumonia, or bone and joint infection;
4. Chronic diarrhea or stools characteristic of malabsorption;
5. Repeated infections without intervening periods of good health;
6. hronic eczema and alopecia; and
   
7. Frequent fever.

Immunodeficiency is less likely if infections are associated with a strong family history of allergies or contact with many other children in the home or nursery school. AIDS is rapidly becoming the most common severe immunodeficiency disorder, even in children.

Ref: Behrman RE, Kliegman RM, Arvin AM (eds): Nelson Textbook of Pediatrics, ed 15. WB Saunders Co, 1996, pp 916-919.

The Correct ANSWER is : B

After a large local reaction to a sting, most people have positive skin tests, suggesting that an allergic reaction is involved. Even so, venom immunotherapy is not effective for preventing large local reactions. Cellulitis rarely develops after an insect sting, and antibiotics are not usually required. People who have had large local reactions typically continue to have similar reactions after subsequent stings; the risk of anaphylaxis is less than 5% per episode. Usual medical management for these reactions includes analgesics and antihistamines. Sometimes a short course of oral steroids is required if the swelling is extensive and disabling.

Ref: Reisman RE: Insect stings. N Engl J Med 1994;331(8):523-527.

The Correct answer is D

Hepatolenticular degeneration, also known as Wilson’s disease, is a copper storage disease. In this disease, copper is stored in the liver resulting in chronic inflammation to the liver and eventually liver failure. Wilson’s disease occurs because of a genetic mutation on chromosome number 13. Therefore, there is a familial history of Wilson’s disease. Wilson’s Disease may present with psychiatric changes including dementia, anxiety, depression, schizophrenia, manic depression, drooling, difficulty speaking and tremor.

Wilson’s disease should be suspected in a young patient who presents with hepatitis or culminant hepatic failure even if Kayser-Fleischer rigs are absent around the eye.

Diagnostic criteria include:
Low serum ceruloplasmin levels (<20 mg%)
High liver copper levels (>250 mg/g) and
high 24 hour urinary copper levels (>100 mg/d or >1.6 mmol/d).

The correct Answer is B


The occurrence of agranulocytosis is a hazard of clozapine, but this hazard can be reduced by monitoring the white-cell count. The increasing risk of agranulocytosis with age and the reduced incidence after the first six months of treatment provide additional guidelines for the prescription and monitoring of clozapine treatment in the future. After the FDA approved clozapine, it became available for marketing in the USA in 1990. Potentially fatal agranulocytosis is estimated to occur in 1 to 2 percent of treated patients.

The Correct Answer is A

According to the 2000 National Household Survey on Drug abuse, an estimated 8.8 million people (4.0 percent of the population) have tried methamphetamine at some time in their lives. Data from the 2000 Drug Abuse Warning Network (DAWN), which collects information on drugrelated episodes from hospital emergency departments in 21 metropolitan areas, reported that methamphetamine-related episodes increased from approximately 10,400 in 1999 to 13,500 in 2000, a 30% increase. Although both methamphetamine and cocaine are psychostimulants, there are differences between them.

METHAMPHETAMINE:

Smoking produces a high that lasts 8-24 hours. 50% of the drug is removed from the body in 12 hours

COCAINE:

Smoking produces a high that lasts 20-30 minutes. 50% of the drug is removed from the body in 1 hour.

As a powerful stimulant, methamphetamine, even in small doses, can increase wakefulness and
physical activity and decrease appetite. A brief, intense sensation, or rush, is reported by those who smoke or inject methamphetamines. Oral ingestion or snorting produces a long lasting high instead of a rush, which reportedly can continue for as log as half a day. Both the rush and the high are believed to result form the release of very high levels of dopamine into the brain’s pleasure centers.

Methamphetamine has toxic effects. In animals a single high does of the drug has been shown to
damage nerve terminals in the dopamine-containing regions of the brain. The large release of
dopamine produced by methamphetamine is thougtht to contribute to the drug's toxic effects on nerve terminals in the brain. High doses can elevate body temperature to dangerous, sometimes lethal, levels, as well as cause convulsions.

Long-term methamphetamine abuse may result in addiction. In addition to being addicted to methamphetamine, chronic methamphetamine abusers exhibit symptoms that can include violent behavior, anxiety, confusion, and insomnia. They also can display a number of psychotic features, including paranoia, auditory hallucinations, mood disturbances, and delusions (for example the sensation of insects creeping on the skin, which is called “formication”). The paranoia can result in homicidal as well as suicidal thoughts. With chronic use, tolerance for methamphetamine can develop. In some cases, abusers forgo food and sleep while indulging in a form of binging known as a “run,” injecting as much as a gram of the drug every 2 to 3 hours over several days until the user runs out of the drug or is too disorganized to continue. Chronic abuse can lead to psychotic behavior, characterized by intense paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.


REFERENCE: http://www.drugabuse.gov/ResearchReports/methamph/methamph3.html

The Correct Answer is A. phencyclidine

Phencyclidine intoxication has both psychiatric and physical manifestations. Intoxication may be
viewed as occurring in three stages. Mild intoxication, the first and most common stage, is manifested primarily by psychiatric signs and symptoms. In the second stage, patients are stuporous to comatose, but they have intact deep pain responses. In the third stage, patients do not respond to deep pain stimuli. Treatment depends on the stage of intoxication.

The Correct Answer is D

Tranylcypromine (Parnate) is an antidepressant in the class of Monoamine Oxidase Inhibitors
(MAOIs). Other MAOIs include phenelzine (Nardil) and isocarboxazid (Marplan). Tyramine, vasoactive peptides found in wine, may interact with MAOIs. Foods that contain tyramine can be very dangerous when used in combination with MAOIs and in certain cases the combination even is potentially lethal. Both tyramine and MAOIs produce a raised level of noradrenaline. Examples of foods and drinks containing tryramine are: alcoholic beverages and particularly wine, aged cheeses, chocolate (cocoa), beef and chicken livers.

The Correct Answer is E.

The local effects are usually clearly beneficial, for example the destruction of invading microorganisms; but at other times they appear to serve no obvious function, or may even be positively harmful.

Beneficial effects

Both the fluid and cellular exudates may have useful effects. Beneficial effects of the fluid exudate are as follows:

Dilution of toxins. Dilution of toxins, such as those produced by bacteria, allows them to be carried away in lymphatics.

Entry of antibodies. Increased vascular permeability allows antibodies to enter the extravascular space, where they may lead either to Iysis of microorganisms, through the participation of complement, or to their phagocytosis by opsonisation. Antibodies are also important in neutralisation of toxins.

Drug transport. The fluid carries with it therapeutic drugs such as antibiotics to the site where bacteria are multiplying.

Fibrin formation. Fibrin formation from exuded fibrinogen may impede the movement of micro-organisms, trapping them and so facilitating phagocytosis.

Delivery of nutrients and oxygen. Delivery of nutrients and oxygen, essential for cells such as neutrophils which have high metabolic activity, is aided by increased fluid flow through the area.

Stimulation of immune response. The drainage of this fluid exudate into the lymphatics allows particulate and soluble antigens to reach the local Iymph nodes where they may stimulate the immune response.

Harmful effects

The release of Iysosomal enzymes by inflammatory cells may also have harmful effects:

Digestion of normal tissues. Enzymes such as collagenases and proteases may digest normal tissues, resulting in their destruction. This may result particularly in vascular damage, for example in type III hypersensitivity reactions and in some types of glomerulonephritis.

Swelling. The swelling of acutely inflamed tissues may be harmful: for example, the swelling of the epiglottis in acute epiglottitis in children due to Haemophilus influenzae infection may obstruct the airway, resulting in death. Inflammatory swelling is especially serious when it occurs in an enclosed space such as the cranial cavity. Thus, acute meningitis or a cerebral abscess may raise intracranial pressure to the point where blood flow into the brain is impaired, resulting is ischaemic damage, or may force the cerebral hemispheres against the tentorial orifice and the cerebellum into the foramen magnum (pressure coning).

Inappropriate inflammatory response. Sometimes, acute inflammatory responses appear inappropriate, such as those which occur in type I hypersensitivity reactions (e.g. hay fever) where the provoking environmental antigen (e.g. pollen) otherwise poses no threat to the individual. Such allergic inflammatory responses may be life-threatening, for example extrinsic asthma.

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The Correct Answer is B.

The binding of antibody to its antigen often triggers the complement system through the so-called classical pathway. It can occur in solution or when the antibodies have bound to antigens on a cell surface.

The proteins of the classical pathway

C1

C1 exists in blood serum as a molecular complex containing:

• 6 molecules of C1q
• 2 molecules of C1r
• 2 molecules of C1s

The constant regions of mu chains (IgM) and some gamma chains (IgG) contain a binding site for C1q. (A single molecule of IgM is enough to initiate the pathway. IgG is far less efficient, requiring many molecules to do so.)

• Binding of C1q activates C1s and C1r.
• Activated C1s (a serine protease) cleaves two serum proteins:
  • C4 is cleaved into a large fragment
    • C4b, which binds covalently to sugar residues on cell-surface glycoproteins, and a smaller, inactive, fragment of
    • C4a which diffuses away.
  • C2 is cleaved into
    • C2b, which binds noncovalently to a site on C4b, leaving a smaller, inactive, fragment of
    • C2a which diffuses away.
  • The complex of C4b•2b is called "C3 convertase" because it catalyzes the cleavage of C3. (C4b•2b is also a serine protease.)

The Correct Answer is D.

The movement of neutrophils from the vessel lumen into into a damaged area is mediated by substances known as chemotactic factors, which diffuse from the area of tissue damage. Time-lapse cine photography in experiments shows apparently purposeful migration of neutrophils along a concentration gradient. The main neutrophil chemotactic factors are:

• C5a
• LTB4
• Bacterial components

These factors bind to receptors on the surface of neutrophils and activate secondary messenger systems, stimulating increased cytosolic calcium, with resulting assembly of cytoskeletal specializations involved in motility.

The Correct answer is E.

Prosopagnosia literally means inability to recognise faces. The condition is usually caused by a bilateral lesion of the visual cortex. Depending on the location of the lesion, other types of agnosia are possible.

Anosagnosia refers to a deficit in cognition about one's illness, or the lack of awareness that one is suffering from a certain condition. It is related to large lesions of the non dominant parietal lobe, which causes the patient to be confused, and unaware of motor and sensory deficits.

Confabulation refers to fabrication of stories and events that never happened in order to fillin memory gaps.It is seen mostly in demetias.

Conversion disorder is characteristed by one or more neurologic symptoms (motor,sensory,or changes in the consciousness such as pseudoseizures) associatede with unresolved psychological conflicts. The symptoms are unconscious and develop as a result of repressed anxiety about the unacceptable impulses.

'Ganser syndrome" is one of the "dissociative disorders not otherwise specified". This diagnosis refers to the phenomenon of giving approximate answers rather than exact ones. It is associated with other symptoms like amnesia, disorientation and perceptual disturbances. It is most commonly seen in prison inmates.

The Correct Answer is (D)


The following factors dictate recovery following a nerve repair

♦ Age

• Better prognosis in younger age groups

♦ Tension at the suture line

• Better prognosis with low tension

♦ Time since injury

• After 18 months only sensory functions can be expected

♦ Location of injury

• Better prognosis with distal injuries

♦ Type of Nerve

• A primary motor nerve like radial nerve has a better prognosis than a mixed nerve
  

♦ Condition of the nerve ends

• The more the crushing and infection, the poorer the prognosis

♦ Associated conditions

• Infection, ischaemia etc indicate poor prognosis

The Correct Answer is (B)


Reference: Bailey and Love 24th Edition Page 416

♦ Erb-Duchenne palsy
o Upper Brachial Cord
o C5-C6 roots and upper trunk

♦ Klumpke’s paralysis
o Lesion of lower roots

The correct Answer is D.

Many micro-organisms / diseases can be transmitted by arthropods:

• Bacteria : plague, borrelia, rickettsiae, bartonella

• Protozoa : malaria, trypanosomiasis, leishmaniasis, babesia

• Worms : filaria, minor tapeworms (Hymenolepis sp, Dipylidium caninum)

• Viruses : see below (all arboviruses, by definition)

Some viruses can be transmitted by arthropods and are then called arboviruses. The term ARBO is an abbreviation of "ARthropod BOrne". The name “arbovirus” therefore has no taxonomic value.

• Togaviridae

• Alphaviruses: Chikungunya, Eastern Equine Encephalitis (EEE), Western Equine Encephalitis (WEE), Venezuelan Equine Encephalitis (VEE)

• Flaviviridae

• Flaviviruses: Dengue, Japanese Encephalitis, Yellow fever, West Nile, Russian Spring Summer Encephalitis (RSSE) and the related European Tick-Borne Encephalitis (TBE), Powassan, Murray Valley (Australia). Alkhurma virus is a flavivirus of the TBE-complex, responsable for tick-borne haemorrhagic fever

• Bunyaviridae

• Nairoviruses: Crimean-Congo Haemorrhagic Fever

• Phleboviruses: Rift Valley Fever, Phlebotomus fever (Sicilian and Naples virus)

The correct answer is E

Explanation

Characteristic clinical features of anorexia nervosa include:

• Maintenance of a low body weight less than a body mass index of 17.5.
• Amenorrhoea either primary or secondary in females, in males loss of libido.
• A severe fear of fatness and phobia of normal body weight.
• A distorted body image where the individual does not recognise the degree of their emaciation. In particular as weight is gained they misinterpret changes in body weight and shape.

The correct answer is D

Explanation
Primary hyperparathyroidism is resulting from overactivity of one or more parathyroid glands. This is characterized by hypercalcemia, hypophosphatemia and hypercalciuria. It is caused usually by an adenoma, less commonly by primary hyperplasia. Calcium stones in the urinary tract are frequently present.

Symptoms in primary hyperparathyroidism such as fatigability, anorexia and weakness result from the hypercalcemia. Serum parathyroid hormone level can be determined accurately by radioimmunoassay or immunoradiometric assay.

The correct answer is E

Explanation

The PICA supplies blood to the lateral portion of the medulla, which includes the inferior cerebellar peduncle, vestibular nuclei, descending sympathetic and trigerninal tracts, spinothalamic tracts and the nucleus ambiguous and solitary tract and nucleus.

Lateral medullary infarction produces Wallenberg's syndrome of ipsilateral limb and gait ataxia, dizziness, nystagmus, loss of pain and temperature sensation on the face with loss of corneal reflex, Horner's syndrome, hoarseness and palatal weakness with loss of taste and contralateral loss of pain and temperature sensation on the body.

The correct answer is B

Explanation

Synthesis of ACh requires the uptake into the nerve terminal of choline. Hemicholinium-3 inhibits the plasma membrane pump for choline. In the absence of choline uptake, cholinergic nerves eventually become depleted of ACh. The more cholinergic nerves are stimulated in the presence of HC-3, the more rapidly they fail.

Storage of ACh in synaptic vesicles requires its uptake into synaptic vesicles. Vesamicol is a drug that prevents the uptake pump for ACh in synaptic vesicles. Similar to the effects of HC-3, once a cholinergic nerve is depleted of preformed ACh, then transmission fails.

The release of synaptic vesicles from cholinergic nerve terminals is blocked by botulinus toxin (Botox®). This effect is useful both experimentally and clinically.

The correct answer is D

Explanation

There is an increased risk for the development of torsades de pointes, a potentially fatal arrhythmia, when the QT interval is prolonged. Roden reviewed the drugs most commonly implicated in QT prolongation and the clinical factors that increase the risk of torsades de pointes.

Medication-induced QT prolongation was first recognized with the use of quinidine in the 1920s. Roden lists other drugs that also are implicated in prolongation of the QT interval and may cause torsades de pointes . Use of these medications, especially when a congenital QT prolongation syndrome or other clinical risk factor is present, increases the chance that torsades de pointes may develop. Because the risk of torsades de pointes is sufficiently high at typical clinical dosages of sotalol, dofetilide, and ibutilide, the review author recommends inhospital cardiac monitoring when therapy with these agents is initiated. 

The risk of torsades de pointes is not related linearly to the degree of QT prolongation, although any drug that prolongs the QT interval beyond 500 msec is thought to confer an elevated risk. Heart rate exerts an important effect on the risk for associated torsades de pointes, with a greater propensity for developing the arrhythmia when bradycardia is present.

The correct answer is B

Explanation

Lacunes are caused by occlusion of a single penetrating artery. The deep penetrating arteries are small nonbranching end arteries (usually smaller than 500 mm in diameter), which arise directly from much larger arteries (eg, the middle cerebral artery, anterior choroidal artery, anterior cerebral artery, posterior cerebral artery, posterior communicating artery, cerebellar arteries, basilar artery). Their small size and proximal position predispose them to the development of microatheroma and lipohyalinosis.

Lacunar strokes, which comprise the most common paradigm of small vessel infarction, account for 10% of all strokes. Several distinct lacunar syndromes are recognized: the most common is pure motor herniparesis. The clinical characteristics of this syndrome include severe herniparesis or herniplegia involving the limbs, face and trunk often with associated dysarthria. Notably absent are sensory disturbance, visual or language deficits.

The site of such infarctions are within the corona radiata, internal capsule, cerebral peduncle, pons and rarely the medullary pyramid. The pure sensory stroke produces hemisensory deficits involving the face, limbs and trunk contralateral to the small infarction in the ventral posterior thalamic nucleus which causes the syndrome.

Lacunar infarction in the genu or anterior limb of the internal capsule or pontine base produce clumsy hand-dysarthria syndrome which manifests clinically as clumsiness of the contralateral hand and tongue with contralateral facial paresis. Homolateral ataxia and crural paresis result from pontine lacunes involving post-decussating cerebellar tracts and pre-decussating corticospinal tracts. The resultant signs are of mild contralateral hemiparesis involving leg more than arm or face with more marked ataxia of the weak limbs.

Bilateral lacuries within the internal capsule in perithalamic locations may result in a mutism syndrome. The accrual of multiple lacunae within the internal capsules of both hemispheres may result in a pseudobulbar syndrome in which there is dysarthria, hyperactive gag reflex with dysphagia, spasticity especially of the lower limbs extensor plantar reflexes, gait apraxia with small hesitant steps and emotional incontinence. This lacunar state is a major part of subcortical atherosclerotic encephalopathy.

There is evolving evidence that microvascular occlusive disease can be due not only to thrombotic or obliterative disease but also to embolic processes. Intra. and extracranial arterial sources are implicated as is cardioembolism of microparticulate matter.

The correct answer is B

Explanation

The glossopharyngeal (ie, CN IX), vagus (ie, CN X), and accessory (ie, CN XI) nerves emerge cranial to caudal, in that order, from the ventral medulla, lateral to the medullary olive. From there, they course toward the jugular foramen and exit the skull base at the jugular foramen.

The glossopharyngeal nerve is located in the pars nervosa of the jugular foramen, and the vagus and accessory nerves are located within the more posterior pars vascularis. The hypoglossal nerve (CN XII) is formed by the fusion of multiple rootlets that emerge from the ventrolateral sulcus between the medullary olive and pyramid. The nerve exits the cranial vault via the hypoglossal canal, then lies medial to CN IX, CN X, and CN XI.


Schwannomas in the jugular foramen that arise from the glossopharyngeal, vagus, or accessory nerves, can present with variable cerebellar and acoustic symptoms, depending on the extent of the intracranial growth of the mass. They also can cause glossopharyngeal dysfunction (eg, hoarseness, difficulty swallowing) and/or spinal accessory symptoms (eg, trapezius atrophy).


Schwannomas of the jugular foramen are rare. Patients often present with symptoms consistent with eighth cranial nerve injury or cerebellar or brain stem compression. Symptoms relating to injury of the ninth or 10th to 12th cranial nerves are less common. Although the clinical presentation of a schwannoma of the jugular foramen may suggest the presence of a vestibular schwannoma, appropriate imaging techniques and interpretation should permit correct differentiation of tumor origin and type and suggest the appropriate surgical approach.

Schwannoma of the jugular foramen appears as a sharply demarcated, contrast-enhancing tumor, which is typically centered or based in an enlarged jugular foramen with sharply rounded bone borders having a sclerotic rim.


The clinical presentation of schwannomas of the jugular foramen varies significantly according to the tumor's growth pattern. Deafness, vertigo, and ataxia were present if the mass is intracranial. Most patients present with symptoms of decreased hearing; Hoarseness and weakness of the trapezius and sternocleidomastoid muscles occur in some patients in whom the tumor is within the bone or extracranial.



In patients with a large proportion of the tumor below the skull base, the symptoms tended to reflect glossopharyngeal injury.

The correct answer is B

Explanation

The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support. It consists of an inflatable silicone mask and rubber connecting tube. It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation. All parts are latex-free.

The Laryngeal Mask Airway is an appropriate airway choice when mask ventilation can be used but endotracheal intubation is not necessary.
Contraindications:
Non-fasted patients
Morbidly obese patients
Obstructive or abnormal lesions of the oropharynx

Advantages:
Allows rapid access
Does not require laryngoscope
Relaxants not needed
Provides airway for spontaneous or controlled ventilation
Tolerated at lighter anesthetic planes

Disadvantages:
Does not fully protect against aspiration in the non-fasted patient
Standard LMA does not allow high positive pressure ventilation
Requires re-sterilization

Special Features:
May be used as a rescue airway and fiberoptic conduit when intubation is difficult, hazardous or unsuccessful. It can be used for bronchoscopy in the awake or asleep patient

The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anaesthetic practice. Despite widespread use, the definitive role of the laryngeal mask has yet to be established. In some situations, such as after failed tracheal intubation or in anaesthesia for patients undergoing laparoscopic or oral surgery, its use is controversial. There are a number of unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoid pressure prevents placement of the mask. The laryngeal mask may be used in circumstances other than airway maintenance during anaesthesia: fibreoptic bronchoscopy, tracheal intubation through the mask and cardiopulmonary resuscitation

The correct answer is D

Explanation
The receptors for the Tumor necrosis factor are on several mononuclear cells, in the synovial membrane, as well as the peripheral blood and synovial fluid. There are also soluble receptors - receptors that are free in solution. These are shed from mononuclear cells. Increased soluble receptors are seen in RA, SLE, Systemic sclerosis, MCTD, RA, and to a certain degree OA, although the latter is less than the levels in RA.


The soluble TNF receptors block the TNF by mopping up and blocking the levels of TNF, so that less is available to activate the mononuclear cells. They thus act as natural inhibitors. The incidence and extent of the levels of the soluble receptor correlates with disease activity.

The correct answer is E

Explanation

The symptoms (anorexia, nausea, and brown urine) are typical of hepatitis. The body fights viral infections by CD8+ T cell-mediated lysis of infected cells that present viral antigens on their surface. The viral surface antigen does not directly injure hepatocyte membranes .

The role of the host immune response in determining clinical outcome following hepatitis B virus (HBV) infection is well recognized. In patients infected with hepatitis B, therapies, diseases, or conditions that impair specific lymphocyte responses lead to a high rate of chronic infection; in addition, the vigor of the host T-cell response to HBV-encoded antigenic peptides appears to correlate directly with the degree of acute hepatocellular injury and inversely with levels of HBV viremia. IgM directed against core antigen does not cause the hepatocytes to lyse.

The correct answer is A

Explanation

Atherothrombosis of the PCA is relatively uncommon, but when it occurs is generally in the proximal segment of the vessel. Sometimes thrombus may spread by contiguous ascent from the basilar apex.

PCA infarction rarely involves the entire arterial territory; and the variability of the resulting clinical deficits of primary sensory, visual and behavioral fiinction depend upon the degree of damage to the thalamus, occipital and inferomedial temporal lobes respectively.

Blockage of vessels derived from the proximal PCA can cause infarction in sensory and motor nuclei of the thalamus and nearby subthalamic structures. Such is the case when the thalamogeniculate branch is occluded, producing a distinctive syndrome of transient contralateral herniballismus and herniparesis with persistent hemihypesthesia and fleeting but recurrent contralateral pain .

When PCA infarction occurs as the result of occlusion beyond its proximal stem, obtundation and sleep disturbances are not present as reticular activating structures are spared. Herniparesis and third nerve dysfunction are absent because the cerebral peduncle is not injured.
Unilateral infarction of cerebrocortical structures within the occipital cortex manifest as contralateral hemianopia often sparing the macular region due to the dual supply of the occipital pole by PCA and MCA or ACA branches. With incomplete lesions of the primary visual receptive area of the calcarine region of the occipital lobe, the hernianopic loss may be more marked in the contralateral superior fields and less impaired in the inferior fields. With large cortical lesions involving occipital and temporal regions, a variety of behavioral syndromes may be present.

Lesions of this type in the dominant hemisphere can produce alexia, anomia and amnesia. These deficits often occur without agraphia. The ability to name colors or recognize nonverbal symbols such as musical notes may be particularly impaired. When the non-dominanthemisphere is involved, spatial disorientation and the anomia for familiar faces (prosopagnosia) can occur.

Bilateral PCA infarcts of the temporal lobes may produce lesions of both hippocampi leading to a permanent severe amnesia termed Korsakoff's state. Bilateral infarction of the occipital lobes can produce Balint's syndrome of disordered volitional eye movements (ocular apraxia), imprecise visually guided eye movements (ocular ataxia), impaired visually guided limb movements (optic ataxia) and the inability to recognize and name multiple concomitantly viewed objects (simultanagnosia).

The correct answer is B

Explanation

Ataxia, lightning pains, a positive Romberg sign, areflexia, and a lack of vibratory or position sensation can all be seen with tabes dorsalis which is due primarily to the involvement of the dorsal roots.

A patient with Friedreich's ataxia (choice a) will also present with a loss of position and vibratory sensation in the lower extremities as well as a positive Romberg sign, however, the age of the patient is not consistent with a diagnosis of Friedreich ataxia. Friedreich ataxia usually begins when patients are children and there is ataxia in very young adulthood. It leads to patients being wheelchair bound or bedridden in young adulthood, which was not the case here.

The deep tendon reflexes would be present or increased in amyotrophic lateral sclerosis (choice c). Typically there is a lack of sensory changes with ALS as well.

Cerebellar ataxia (choice d) is not affected by visual input. Since his swaying was present only with his eyes closed, cerebellar ataxia is not correct.

Polio (choice e) is a disease that affects that anterior horn and therefore motor function is affected; strength would not be adequate. Although ataxia can be seen with polio, the sensory changes in this scenario would not be found.

The correct answer is B

Explanation

Molecular genetic research has demonstrated that familial hypertrophic cardiomyopathy is caused by a mutation in one of nine genes that encode sarcomere proteins. Sarcomeres are the contractile units within the cardiac cells; these are composed of many proteins that are organized into thin and thick filaments. These filaments slide with respect to each other during cardiac contraction.

Mutations in thick filament proteins called cardiac B myosin heavy chain or cardiac myosin binding protein-C appear to account for approximately 82% of hypertrophic cardiomyopathy.

Mutations in thin filament proteins cardiac troponin T and a tropomyosin account for about 13% of hypertrophic cardiomyopathy.

Mutations in two other sarcomere proteins, the myosin regulatory and essential light chains are quite rare and contribute less than 5% to hypertrophic cardiomyopathy.

Although these percentages are only estimates, they indicate that more disease-causing genes will be identified. A tenth gene has been identified that is a non-sarcomere protein (a subunit of protein kinase A) is associated with individuals who have both hypertrophic cardiomyopathy and Wolf-Parkinson-White syndrome.

The correct answer is D

Explanation

Henoch-Schonlein purpura mainly affects the arterioles and capillaries, with peak incidence between 4 and 11 years of age, although adults may also be affected. The syndrome occurs most often in spring, following a viral upper respiratory infection. Other inciting agents associated with HSP include insect stings and drugs.

The rash is accompanied by arthralgias of the lower extremities, most commonly the ankles, with swollen tender joints. Frank arthritis is usually absent. Gastrointestinal complaints, seen in 70% of patients, include abdominal pain, nausea, vomiting, and diarrhea, associated with blood and mucus per rectum.

Renal involvement occurs in 50% of patients with hematuria and red-cell casts; however, it rarely progresses to renal failure. Nervous system involvement is rare, especially in children. The syndrome is relapsing and remitting over several weeks.

The immune complex deposition is IgA, with antigens to drugs, infectious agents, foods, insect bites, and immunizations implicated in the pathogenesis.

The correct answer is D

Explanation

In hemoglobin, each subunit contains a heme group. Each heme group contains an iron atom that is able to bind to one oxygen (O2) molecule. Therefore, each hemoglobin protein can bind four oxygen molecules

The correct answer is B

Explanation

There is no homogeneity to the syndromes or prognosis of patients with complete occlusion or severe stenosis of the BA itself. When the occlusive process is gradual and collateral flow is present, the deficits may be focal and survivable. But when onset is sudden and collateral is limited, the syndrome is devastating and usually fatal.

Such patients experience a short prodrome of headache, confusion and dizziness, followed by a rapid progression through stupor to coma. Dysarthria and lateralized paresthesiae are common, as are pupillary and ocular movement abnormalities.

Facial palsy and herniplegia or quadriplegia accompanied by bilateral extensor plantar reflexes are generally seen. Crossed cranial nerve and herniplegia are often manifested during the progression of signs.

Though fluctuations in depth of coma and severity of paralysis often occurs early, death most frequently occurs within days to weeks.

The correct answer is E

Explanation

This is the point at which axons leave the eyeball and join the optic nerve. Also, arteries enter and veins leave the retina at the optic disk. There are no photoreceptors here, hence it is known as the 'blind spot'. It is a pinky-yellow oval, approximately 2mm in diameter, and situated in the nasal retina

The correct answer is C

Explanation

The first step in this process is the activation of thrombomodulin by thrombin. Subsequently, protein C combines with thrombomodulin in order to produce activated Protein C.

Activated protein C then combines with protein S on the surface of a platelet (platelets are the clotting cells that circulate in the blood and provide phospholipids to support that clotting process).

Activated protein C can then degrade factor Va and factor VIIIa.

Thrombomodulin is an endothelial cell surface bound protein that functions as a cofactor in the thrombin mediated activation of Protein C, a protein circulating in plasma as an inactive zymogen of a serine protease. The activation of Protein C via the thrombin-thrombomodulin complex takes place close to the intact endothelial cell lining of the blood vessels as soon as the coagulation cascade has been initiated.

The correct answer is B

Explanation

In the "locked-in" syndrome, patients with such tegmental-basal pontine strokes are unable to move anything but their eyes despite the preservation of normal consciousness. When the ischernic insult extends into the pontine, tegmental midline nuclei such as those of the fourth and sixth nerves results include dysconjugate eye movements. Other midline structures such as the parapontine reticular formation and the medial longitudinal fasciculus which integrate lateral eye movements may be involved with resulting paralysis or aberration of lateral gaze, including para-abducens palsy and internuclear ophthalmoplegia respectively

The correct answer is D

Explanation

Diazoxide works by causing the muscle in the walls of the blood vessels (arteries) to relax. This allows the arteries to widen rapidly and reduces blood pressure.

Diazoxide injection is mainly used for the short-term, emergency treatment of very high blood pressure (hypertensive crisis) associated with brain disorder, heart failure, liver or kidney disease or pregnancy. It is also used to reduce extremely high blood pressure caused by kidney disease and in cases where other medicines have not been effective. It is not suitable for long term treatment of high blood pressure as it increases blood sugar levels.

Diazoxide injection is also used to reduce the blood pressure in hypertensive patients who are about to undergo invasive diagnostic procedures such as a kidney biopsy. This reduces the risk of bleeding.

The correct answer is C

Explanation

Propranolol is a non selective beta adrenoreceptor blocking drug which is commonly used as an anti-hypertensive agent. Due to it beta blocking effect it also suppresses palpitations, tachycardia and resting tremors.

Sulphonylurea drugs are commonly used oral hypoglcemics in diabetic patients. The most common side effect of these drugs is hypoglycemia which can be fatal if not detected immediately.The earliest symptoms of hypoglycemia are palpitations and tremors of hands.In case the patient is on propranolol these early signs of hypoglycemia will get suppressed and the patient will not realize that he is getting hypoglycemic.

Thus propranolol can mask hypoglycemia in a patient on sulphonylurea drugs which can prove fatal. Therefore propranolol is contraindicated in patients on sulphonylureas. Propranolol does not affect the blood glucose levels nor does it react with sulphonylureas. It is an effective anti-hypertensive drug in diabetic patients but not used with sulphonylurea drugs due to the above explained reasons.

The correct answer is C

Explanation

Acute chest syndrome often develops rapidly in patients with sickle cell disease and results in substantial morbidity for these patients. Patients often present with few findings and then rapidly become critically ill. Previously, no predictors as to which patients will develop Acute chest syndrome have been identified, but our data indicate that Secretory phospholipase A2 elevation predicts impending Acute chest syndrome 24 to 48 hours before it is diagnosed clinically.

Elevated Secretory phospholipase A2 in combination with fever is particularly helpful in identifying patients who will develop Acute chest syndrome. Other, more traditional indicators of pulmonary disease, including chest pain, respiratory symptoms, and auscultatory findings, either occur too late or do not occur in many patients who will develop Acute chest syndrome .

Therefore, Secretory phospholipase A2 appears to be a useful parameter for the clinician following sickle cell disease patients with vaso-occlusive crisis .

The correct answer is C

Explanation

A number of drugs may cause pericarditis, including hydralazine, procainamide, phenytoin, dantrolene, phenylbutazone, isoniazid, and the anthracycline class of chemotherapeutic agents.

The correct answer is A

Explanation

Acetylcholine (ACh) is the chemical neurotransmitter for both peripheral and central cholinergic receptors. These cholinoceptive sites are further divided into nicotinic and muscarinic ACh receptors because of its relative specificity of action toward cholinomimetic [L(+) muscarine, S(-) nicotine] and cholinergic blocking agents (d-tubocurarine, atropine).

Nicotinic ACh receptors are selectively stimulated by nicotine and blocked by curare, C6 and C10.

Muscarinic ACh receptors are activated by L (+) muscarine and blocked by atropine. It should be noted that nicotine acts at nicotinic sites to produce stimulation in low doses blockade in high doses.

The correct answer is B

Explanation

When certain types of fungus grow on food, they produce minute amounts of toxins called mycotoxins. Most fungi-produced mycotoxins are harmless, and even helpful. For example, the antibiotic penicillin came from a fungus, and it is a mycotoxin. Some of these fungi (primarily Aspergillus flavus) produce the very lethal mycotoxins called aflatoxins. Aflatoxins are remarkably potent, often causing disease even when ingested in minute amounts. Aflatoxins can cause disease throughout the body, but are most commonly known for causing acute or chronic liver disease and liver cancer.

The correct answer is C

Explanation

Elevated HbA1c at the time of conception has been shown to be associated with a marked increase in congenital malformations, and 30 to 50 % of perinatal mortality in diabetic pregnancy is due to fetal malformations.

Sacral agenesis and caudal dysplasia are 400 times more frequent in diabetic than in normal pregnancies. Other anomalies associating with diabetes during first trimester include open spina bifida, anencephaly, renal agenesis, ventricular septal defects, and great vessels transposition. Offspring of diabetic women also face specific risks during late pregnancy, mostly related to deficits in placental exchanges of oxygen and nutrients.

Delivery before 37 weeks is associated with an increased risk of RDS, while delivery after 40 weeks carries an unacceptable risk of fetal demise. Women with poorly controlled diabetes should therefore probably be delivered at 37-38 weeks, after testing for lung maturity.

The correct answer is A

Explanation


A working definition for acute evolving myocardial infarction in the presence of clinically appropriate symptoms has been established as


(1) patients with ST-segment elevation, i.e. new ST-segment elevation at the J point with the cut-off points 0.2mV in V1through V3and 0.1mV in other leads, or

(2) patients without ST-segment elevation, i.e. ST-segment depression or T wave abnormalities.

Clinically established myocardial infarction may be defined by any Q wave in leads V1through V3, or Q wave 0.03s in leads I, II, aVL, aVF, V4, V5or V6.


Neither the GISSI-2/International Trials nor the Third International Study of Infarct Survival(ISIS 3)found a difference in mortality between the use of streptokinase and tissue plasminogen activator or anistreplase. Furthermore, the addition of subcutaneous heparin did not reduce mortality compared with the use of no heparin.


However, the GUSTO Trial (Global Utilisation of Streptokinase and Tissue Plasminogen Activator for occluded coronary arteries)28 employed an accelerated t-PA (tissue type plasminogen activator) regimen given over 90min29 rather than the previously conventional period of 3h. Accelerated t-PA with concomitant APTT (activated partial thromboplastin time) adjusted intravenous heparin was reported to result in 10 fewer deaths per 1000 patients treated. The risk of stroke is higher with t-PA or anistreplase than with streptokinase.


In the GUSTO trial, there were three additional strokes per 1000 patients treated with accelerated t-PA and heparin in comparison with streptokinase and subcutaneous heparin, but only one of these survived with a residual deficit. In assessing the net clinical benefit, this must be taken into account with the reduced death rate in the t-PA group. Several variants of t-PA have been studied. Double-bolus r-PA (reteplase) does not offer any advantage over accelerated t-PA except for its ease of administration. Single-bolus weight-adjusted TNK-tPA (tenecteplase) is equivalent to accelerated t-PA for 30-day mortality and associated with a significantly lower rate of non-cerebral bleeds and less need for blood transfusion.


Bolus fibrinolytic therapy may facilitate more rapid treatment in and out of the hospital and reduce the risk of medication errors. The choice of fibrinolytic agent will depend on an individual assessment of risk and benefit, and also on factors such as availability and cost. For late treated patients more fibrin-specific agents may be more effective

Platelet aggregation is only partly inhibited by aspirin and progress has been made with the development of platelet glycoprotein IIb/IIIa inhibitors, which block the final pathway of platelet aggregation. Angiographic trials demonstrated that the combination of GP IIb/IIIa inhibitors with half-dose fibrinolytic and reduced doses of heparin, induces similar or slightly higher TIMI grade 3 flow rates when compared with full-dose fibrinolytic alone and is associated with more complete resolutionof ST-segment elevations, suggesting an improvement in tissue reperfusion. The clinical benefit and safety of these combinations has been tested in two large trials.No reductions in 30-day mortality or intracranial haemorrhage rates but lower rates of in-hospital reinfarction were observed, however, at the cost of an increase in (mostly spontaneous) non-cerebral bleeding complications especially in elderly patients.

Therefore, the routine use of a reduced dose fibrinolytic with abciximab or other platelet glyco-protein IIb/IIIa inhibitors cannotbe recommended. Whether this combination therapy may be beneficial in specific subgroups of patients (for example those at high risk or those likely to undergo early PCI) needs to be further evaluated.

Heparin has been extensively used during and after fibrinolysis, especially with tissue plasminogen activator. Heparin does not improve immediate clot lysis but coronary patency evaluated in the hours or days following thrombolytic therapywith tissue plasminogen activator appears to be better with intravenous heparin. No difference in patency was apparent in patients treated with either subcutaneous or intravenous heparin and streptokinase.Prolonged intravenous heparin administration has not been shown to prevent reocclusion after angiographically proven successful coronary fibrinolysis. Heparin infusion after tissue plasminogen activator therapy may be discontinued after 24–48h. Close monitoring of intravenous heparin therapy is mandatory; aPTT values over 70s are associated with higher likelihood of mortality, bleeding and reinfarction. Although no randomized trials have beenperformed, there is evidence from recent trials suggesting that more frequent monitoring of aPTT and a full weight adjustment of heparinmay decrease the risk of non-cerebral bleeding complications.

http://eurheartj.oxfordjournals.org/cgi/content/full/24/1/28

The correct answer is E

Explanation
Anti-SSB (or Anti-La)
The specificity of antibodies to Ro (SS-A) and La (SS-B) in Sjogren's syndrome (SS) has been studied by counterimmunoelectrophoresis and immunodiffusion.


Anti-Ro was found in 56% and anti-La in 42% of patients with SS and in 38% and 6% respectively in SLE. Anti-La was rare (less than 1%) in other connective tissue diseases.

These data confirm that anti-La, but not anti-Ro, has a high diagnostic specificity for Sjogren's syndrome and merits inclusion as separate diagnostic criterion for the disease.

The correct answer is A .

Explanation

The cause of amyoplasia is unknown, but children with this disorder have a decreased number of anterior horn cells in the spinal cord, suggesting a neuropathic cause. Other studies have shown that the disorder may be myopathic in origin. In the latter instance, diminution of in utero movement may be the final common pathway leading to contractures.

Every child presenting with multiple joint contractures should have a complete musculoskeletal evaluation and genetics consultation. The distribution of involvement of multiple joint contractures is variable. The classic presentation involves the upper and lower extremities. The lower extremities are typically more involved than the upper extremities. Involvement of all four extremities is quadrimelic involvement.

It is also possible that only the lower extremities or upper extremities (bimelic) may be involved. It is unusual to see only one extremity or a portion of one extremity (monomelic) involved.

The correct answer is A

Explanation

An example of a selective alpha-receptor antagonist is phenoxybenzamine.
Phenoxybenzamine belongs to a class of medicines called the alpha adrenergic blockers. It works by blocking alpha receptors in certain parts of the body.

Alpha receptors are present in the muscle that lines the walls of blood vessels. When the receptors are blocked by phenoxybenzamine, the muscle relaxes and the blood vessels widen. This widening of the blood vessels results in a lowering of blood pressure.

This medicine can be used to treat high blood pressure. This medicine is used in the short term treatment of severe hypertensive episodes associated with phaeochromocytoma

The correct answer is A

Explanation

Primary biliary cirrhosis tends to occur in women in the fifth to seventh decade of life. Primary biliary cirrhosis can be heralded by itching. The itching may start with pregnancy, and it continues after the pregnancy. Anti-mitochondrial antibodies are present with primary biliary cirrhosis. Alkaline phosphatase is elevated with primary biliary cirrhosis.

Hepatitis B has an incubation period of 4 weeks to 6 month, which is not the time frame presented in this scenario. In addition, pruritis and anti-mitochondrial antibodies would not be present.

Hepatocellular carcinoma is associated with long-standing liver disease, such as cirrhosis or hepatitis B or C, which is not the case here. Pruritis and anti mitochondrial antibodies would not be present in hepatocellular carcinoma.

Laennec's cirrhosis is associated with heavy alcohol use over many years. Pruritis and anti mitochondrial antibodies would not be present in Laennec's cirrhosis.

The incubation period for hepatitis A is 2-6 weeks, which is not the time frame presented in this scenario. Pruritis and anti mitochondrial antibodies would not be present in hepatitis A.

The correct answer is A

Explanation

Freudian defense mechanisms - Denial Refusing to acknowledge an undesirable experience, memory. or internal need that is anxiety arousing and behaving as if it did not exist

The correct answer is B

Explanation
Neutrophils, which are also known as polymorphonuclear leukocytes (PMN), represent 50 to 60% of the total circulating leukocytes and constitute the ''first line of defence'' against infectious agents or ''nonself'' substances that penetrate the body's physical barriers. Once an inflammatory response is initiated, neutrophils are the first cells to be recruited to sites of infection or injury.

The correct answer is B

Explanation

Pautrier's microabscesses (an atypical lymphoid cell in a vesicle within the dermis) is seen with mycosis fungoides. Pautrier's microabscesses would not be seen with eczematous dermatitis (choice a), psoriasis (choice c), atopic dermatitis (choice d) or pityriasis rosea (choice e).

The correct answer is C

Explanation

Gonococcal arthritis is the most common type of nontraumatic acute monoarthritis in young, sexually active persons in the United States. It is three to four times more common in women than in men.

Nongonococcal septic arthritis, the most destructive type, generally is monoarticular (80 percent of cases) and most often affects the knees (50 percent of cases).
Staphylococcus aureus is the most common pathogen in nongonococcal septic arthritis (60 percent in some series), but non-group-A beta-hemolytic streptococci, gram-negative bacteria, and Streptococcus pneumoniae can be present.

Anaerobic and gram-negative infections are common in immunocompromised persons.

Inflammation of a single large joint, especially the knee, may be present in Lyme disease. Mycobacterial, fungal, and viral infections are rare. Monoarticular inflammation can be the initial manifestation of human immunodeficiency virus (HIV) infection.

Many types of crystals can trigger acute monoarthritis, but monosodium urate (which causes gout) and calcium pyrophosphate dihydrate (CPPD, which causes pseudogout) are the most common. Calcium oxalate (especially in patients who are receiving renal dialysis), apatite, and lipid crystals also elicit acute monoarthritis. Transient arthritis sometimes results from intra-articular injection of corticosteroids. Osteoarthritis may worsen suddenly and manifest as pain and effusion. Spontaneous osteonecrosis may occur in patients with risk factors such as alcoholism or chronic corticosteroid use. Aseptic loosening is often the source of pain in a prosthetic joint. Infection, commonly from a skin source, is also possible and requires urgent attention.

The correct answer is B

Explanation

Absorption follows first order kinetics when the absorption velocity is proportional to the concentration of the drug, i.e., a constant fraction of the total amount of drug present is transported in equal units of time. So, if 50 percent of the amount present is absorbed in 12 minutes, then 50 percent of what is left will be absorbed over the next 12 minutes. Thus, a total of 75% will be absorbed in 24 minutes.

The elimination of chloramphenicol from the serum following its i.v. administration shows a steady decrease in concentration as the drug is eliminated.

Administration of this form, either by solution or by rapidly dissolving solids (i.e. pills) often obey first-order kinetics. Absorption is characterized by evaluating the absorption rate constant ka from plasma concentration versus time data graphs.

The correct answer is A

Explanation

Spironolactone is effective in lowering the systolic and diastolic blood pressure in patients with primary hyperaldosteronism. It is also effective in most cases of essential hypertension, despite the fact that aldosterone secretion may be within normal limits in benign essential hypertension.

Through its action in antagonizing the effect of aldosterone, spironolactone inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss.

Hyperkalemia: Hyperkalemia may occur in patients treated with spironolactone if the potassium intake is excessive. This can cause cardiac irregularities, some of which may be fatal. Hyperkalemia may also occur even in the absence of potassium supplementation, particularly in patients with impaired renal function, elderly patients, or patients with diabetes. Consequently, no potassium supplementation should ordinarily be given with spironolactone. Hyperkalemia can be treated promptly by rapid i.v. administration of glucose (20 to 50%) and regular insulin, using 0.25 to 0.5 units of insulin/g of glucose. This is a temporary measure to be repeated if required. Spironolactone should be discontinued and potassium intake (including dietary potassium) restricted.

Hyponatremia: During the administration of spironolactone, patients suffering from sodium depletion must be attentively monitored and signs of electrolyte imbalance must be carefully checked.
Spironolactone may, if administered concomitantly with other diuretics, cause or aggravate hyponatremia, as manifested by dryness of the mouth, thirst, lethargy, and drowsiness.

Metabolic Effects:

Hyperchloremic metabolic acidosis: Spironolactone may induce or worsen hyperchloremic metabolic acidosis.

The correct answer is A

Explanation

Sequential monoarthritis in several joints is characteristic of gonococcal arthritis or rheumatic fever.

Monoarthritis occasionally is the first presenting symptom of an inflammatory polyarthritis such as psoriatic arthritis but is an unusual initial symptom of rheumatoid arthritis.

When the history reveals longstanding symptoms in a joint, exacerbations of preexisting disease (e.g., worsening of osteoarthritis with excessive use) should be differentiated from a superimposed infection.

In patients with rheumatoid arthritis, pain in one joint out of proportion to pain in other joints always suggests infection.

Sexual history and history of illegal drug use, alcohol use, travel, and tick bites should be ascertained. Reactive arthritis sometimes can develop after a gastrointestinal or sexually transmitted disease.

Certain occupations, such as farming and mining, frequently are associated with overuse injures and osteoarthritis.

The correct answer is C

Explanation

These antibodies, also known as anticardiolipin antibodies, target certain parts of a cell's membrane. They are detected through special blood tests in about a third of SLE patients. When found in the presence of certain other factors, these antibodies affect blood clotting, leading to: miscarriages, strokes and low platelet counts.

The correct answer is A

Explanation

Serious toxicity has occurred when phenytoin has been given with a variety of enzyme inhibitors, including cimetidine, chloramphenicol and co-trimoxazole. Increases in phenytoin concentrations of less clinical significance have occurred with several drugs, including omeprazole, ceftriaxone, isoniazid and dextropropoxyphene

The correct answer is C

Sotalol is a Class III antiarrhythmic agent that blocks K+ channels, prolongs action potential duration (APD), and lengthens QT interval. Noncardiac selective beta-adrenergic blocker. The D-isomer has less than 1/50 beta-blocking activity of the L-isomer. Sotalol possesses 30% of beta-blocking activity of propranolol

The correct answer is C

Explanation

When the MCA is occluded at its stem, the deep penetrating lenticulostriate arteries which supply parts of the internal capsule and basal ganglia may be blocked and there is compromised flow to the more superficial branches supplying the overlying cortex. An infarction within these territories produces contralateral herniplegia, hemianesthesia and homonymous hemianopia. When in the dominant hemisphere, severe aphasia is present; and when in the non-dominant hemisphere, hemineglect or other agnostic deficits are often present.

If an embolus occludes one of the first order divisions of the middle cerebral artery, deficits arise that may be difficult to distinguish from internal carotid occlusive syndromes. Superior division of the MCA territory infarction yields contralateral, dense sensory and motor appendicular and facial weakness and, if within the dominant hemisphere, severe aphasia. Inferior division infarctions may be characterized by auditory language and repetition deficits and hernianopic visual problems.

When second order divisions of the MCA are occluded (usually by emboli), the stroke symptoms are less global.

If the first branch of the superior division of the MCA (the ascending frontal artery) is Occluded, then the third frontal convolution is infarcted, and there is contralateral brachiofacial weakness.

When this occurs in the dominant hemisphere, the damaged region includes Broca's area; and the initial presentation also includes mutism or dysfluency with little or no difficulty in verbal comprehension. When the territory of the second branch of the superior division of the MCA (the rolandic branch) is infarcted, there is contralateral sensory and/or motor weakness accompanied by articulatory difficulties (dysarthria), but not aphasia.

Occlusion of the third (ascending parietal) or fourth (posterior parietal) branches of the superior division of the MCA produces syndromes characterized by disconnected language function such as conduction aphasia and impairment of planned motor tasks (ideomotor apraxia). Often there is no concurrent primary sensory or motor dysfunction on either side of the body.

The specific syndromes associated with occlusion of the branches of the inferior division of the MCA of the dominant hemisphere include Wernicke's aphasia, often in combination with contralateral superior quadrantanopia because of infarction of white matter tracts deep to the posterior sylvian region including the optic radiation.