APPG 2013; 041-060

41. Lymphatics from Glans of clitoris drain directly into 

A. internal iliac 

B. external iliac 

C. superficial inguinal 

D. gland of cloquet 

Ans b 

The glans penis, the glans clitoris, labia minora, and the terminal inferior end of the vagina drain into deep inguinal nodes and external iliac nodes 

42. In Mayer Rokitansky Kuster Hauser syndrome the following features are present, EXCEPT 

A. Well developed breasts 

B. Absence of vagina 

C. Mullerian agenesis 

D. Inguinal testis 

Ans D 

The following may be observed in patients with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome: 

• Primary amenorrhea and possible cyclic abdominal pain 

o These symptoms are common in individuals with Mayer-Rokitansky-Kuster-Hauser syndrome. 

o The patient undergoes puberty with normal thelarche and adrenarche; however, menses do not begin. 

o Patients may report cyclic abdominal pain due to cyclic endometrial shedding without a patent drainage pathway. 

• Because ovarian function is normal, patients experience all bodily changes associated with menstruation and puberty. 

o Normal secondary female sexual characteristics are present after puberty. 

o Height is normal. 

o Speculum examination of the vagina may be impossible or difficult because of the degree of vaginal agenesis. 

o The vulva, labia majora, labia minora, and clitoris are normal. 

o A palpable sling of tissue may be present at the level of the peritoneal reflection. 

@43. In a 24 year old nulliparous woman with third degree utero vaginal prolapse, the operation of choice is 

A. Purandare's cervico pexy 

B. Shirodkar's sling operation 

C. Le Fort's repair 

D. Extended Manchester operation 

Ans b 

Extended Manchester operation : for cervical elongation 

Le Fort's repair : for older women 

44. The following feature is NOT present in Kallman's syndrome 

A. Bilateral absence of vas deference 

B. Anosmia 

C. Colour blindness 

D. Gonadotrophin deficiency 

Ans A ( Cis also possible ) 

• It is normally difficult to distinguish a case of KS/HH from a straightforward constitutional delay of puberty. However if a boy or girl has not started puberty by either 14 (girls) or 15 (boys) and they have one of the non-reproductive features then a referral to reproductive endocrinologist might be advisable. 

• Reproductive features 

o Failure to start or fully complete puberty in both men and women 

o Lack of testicular development in men; size <3 ml="" span=""> 

o Primary amenorrhoea or failure to start menstruation in women 

o Poorly defined secondary sexual characteristics in both men and women. 

o Infertility 

• Non-reproductive features 

o Hypogonadotropic hypogonadism (a lack of the pituitary hormones luteinizing hormone and follicle-stimulating hormone) 

o Congenital (present from birth) 

o Total lack of sense of smell (anosmia) or markedly reduced sense of smell (hyposmia). This is the defining feature of Kallmann syndrome; it is not seen in other cases of HH. Approximately 50% of HH cases occur with anosmia and can be termed as Kallmann syndrome. 

o Cleft palate or other craniofacial defects. 

o Unilateral renal agenesis or aplasia; absence or non-functioning of one of the kidneys 

o Cryptorchidism; un-descended testicles at birth, occurs in 30% of KS/HH cases 

o Micropenis, occurs in less than 5 to 10% of KS/HH cases 

o Neural hearing defects 

o Synkinesis or mirror movements of hands 

o Dental defects 

o Normally normal stature, but can have an increase in height if treatment is delayed due to the lack of testosterone or oestrogen causing excess bone growth in the arms and legs 

At one stage it was thought that colour blindness was linked to KS/HH but this has proved not to be the case. 

Patients with KS/HH lack a surge of GnRH, LH and FSH that occurs between birth and six months of age.[12] This surge is particularly important in infant boys as it helps with testicular descent into the scrotum. A small percentage of boys with KS/HH will be born with micropenis and/or undescended testes, both of which should be treated and corrected in the first year of life. The surge of GnRH/LH/FSH in non KS/HH children gives detectable levels of testosterone in boys and oestrogen & progesterone in girls. The lack of this surge can sometimes be used as a diagnostic tool if KS/HH is suspected in a newborn boy, but is not distinct enough for diagnosis in girls. 

45. All of the following are present in polycystic ovary syndrome EXCEPT 

A. Elevated luteinizing hormone 

B. Elevated androstenedione 

C. Raised serum hormone binding globulin 

D. Raised serum insulin 

Ans C 

SHBG and polycystic ovarian syndrome (PCOS) 

Sex hormone binding globulin (SHBG) is a protein that binds to both testosterone and estradiol. Its amount can vary widely in patients, and if the SHBG is either low or high, the amount of active (bioavailable) testosterone can vary widely. Therefore, it is very important to measure SHBG in all patients being evaluated for polycystic ovarian syndrome, as well as other patients such as patients with hypopituitarism. 

SHBG is reduced in insulin resistance and actually a very good marker for insulin resistance. Many women with polycystic ovarian syndrome have a high-normal or even a normal total testosterone but have a low SHBG because they have insulin resistance. Therefore, their bioavailable testosterone is often on the high side.

@46. After 72 hours of unprotected coitus, the emergency contraception of choice is 

A. Levonorgestrel 

B. Premarin 

C. Yuzpe method 

D. Copper T 

Ans d 

Copper upto 5 days 

47. The lifespan of Copper T — 380 A is 

A. 3 years 

B. 5 years 

C. 7 years 

D. 10 years 

Ans D 

• Copper T380A has a loading capsule and insertion tube with graduated scale card included. It loads in seconds and can be used as emergency contraception for up to 5 days after unprotected sex. 

• Copper T380A has a shelf life of 7 years and has an intra-uterine life span of 10 years giving your patient a decade of confidence. 

48. Hormone releasing intrauterine device Mirena releases how many microgram of levonorgestrel per day ? 

A. 10 

B. 20 

C. 30 

D. 40 

Ans B 

Mirena is intended to provide an initial release rate of 20 µg/day of levonorgestrel. 

49. Which one of the following regarding "Progestin-only" contraceptive pills is NOT correct ? 

A. Mainly cause anovulation 

B. Can be used in diabetes mellitus 

C. No adverse effect on lactation 

D. Break through bleeding is common 

Ans a 

Breakthrough bleeding or spotting can occur with progestin-only pills 

Lacking the estrogen of combined pills, they are not associated with increased risks of DVT or heart disease. With the decreased clotting risk, they are not contraindicated in the setting of sickle-cell disease. The progestin-only pill is recommended over regular birth control pills for women who are breastfeeding because the mini-pill does not affect milk production (estrogen reduces the amount of breast milk). Like combined pills, the minipill decreases the likelihood of pelvic inflammatory disease. 

It is unclear whether POPs provide protection against ovarian cancer to the extent that COCP do. 

There are fewer serious complications than on COCP 

The mechanism of action of progestogen-only contraceptives depends on the progestogen activity and dose.[1] 

• Very-low-dose progestogen-only contraceptives, such as traditional progestogen-only pills (and subdermal implants Norplant and Jadelle and intrauterine systems Progestasert and Mirena), inconsistently inhibit ovulation in ~50% of cycles and rely mainly on their progestogenic effect of thickening the cervical mucus, thereby reducing sperm viability and penetration. 

• Intermediate-dose progestogen-only contraceptives, such as the progestogen-only pill Cerazette (or the subdermal implant Nexplanon), allow some follicular development (part of the steps of ovulation) but much more consistently inhibit ovulation in 97–99% of cycles. The same cervical mucus changes occur as with very-low-dose progestogens. 

• High-dose progestogen-only contraceptives, such as the injectables Depo-Provera and Noristerat, completely inhibit follicular development (see above) and ovulation. The same cervical mucus changes occur as with very-low-dose and intermediate-dose progestogens. 

50. Which one is NOT TRUE about Nonoxyno1-9 as a contraceptive ? 

A. Immobilizes sperms 

B. Should not be removed for 6 hours after intercourse 

C. Failure rate is about 10/HWY 

D. Increased risk of toxic shock syndrome 

Ans C 

Failure rate 23 /HWY 

Some people are allergic to the spermicide used in the sponge. Women who use contraceptive sponges have an increased risk of yeast infection and urinary tract infection. Improper use, such as leaving the sponge in too long, can result in toxic shock syndrome. 

The sponge can be inserted up to 24 hours before intercourse. It must be left in place for at least six hours after intercourse. It should not be worn for more than 30 hours in a row

51. All are derivatives of neural crest EXCEPT 

A. Schwann cells 

B. Dorsal root ganglion 

C. Adrenal cortex 

D. Melanocytes 

Ans C 

Neural Crest derivatives 

Neural crest cells are a transient, multipotent, migratory cell population unique to vertebrates that gives rise to a diverse cell lineage including melanocytes, craniofacial cartilage and bone, smooth muscle, peripheral and enteric neurons and glia 

Mesectoderm: odontoblasts, dental papillae, the chondrocranium (nasal capsule, Meckel's cartilage, scleral ossicles, quadrate, articular, hyoid and columella), tracheal and laryngeal cartilage, the dermatocranium (membranous bones), dorsal fins and the turtle plastron (lower vertebrates), pericytes and smooth muscle of branchial arteries and veins, tendons of ocular and masticatory muscles, connective tissue of head and neck glands (pituitary, salivary, lachrymal, thymus, thyroid) dermis and adipose tissue of calvaria, ventral neck and face 

Endocrine Cells: chromaffin cells of the adrenal medulla, parafollicular cells of the thyroid, glomus cells type I/II 

Peripheral nervous system: Sensory neurons and glia of the dorsal root ganglia, cephalic ganglia (VII and in part, V, IX, and X), Rohon-Beard cells, some Merkel cells in the whisker Satellite glial cells of all autonomic and sensory ganglia, Schwann cells of all peripheral nerves 

52. Branches of lumbar plexus which emerge from anterior surface of psoas major muscle is 

A. iliohypogastric nerve 

B. ilioinguinal nerve 

C. genitofemoral nerve 

D. obturator nerve 

Ans C 

Branches: 

The small motor branches of the plexus are distributed directly to the psoas major muscle. The large motor branches leave the muscle along its lateral and medial borders and along the anterior surface. Consequently, they are categorized as follows; 

Branches leaving the lateral border of psoas: 

These include the following branches (in order from above downward) 

• Iliohypogastric nerve:?It supplies the skin of lower part of anterior abdominal wall. 

• Ilioinguinal nerve:?It passes through the inguinal canal to supply the skin of groin and scrotum (in males) or labium majus (in females). 

• Lateral cutaneous nerve of thigh:?It crosses the iliac fossa in front of the iliacus muscle and enters the lateral aspect of thigh behind the lateral end of inguinal ligament. It supplies the skin over the lateral surface of thigh. 

• Femoral nerve:?It is the largest branch of lumbar plexus. It enters the thigh lateral to the femoral sheath and supplies various muscles. In the abdomen, it supplies the iliacus muscle. 

Branches leaving the medial border of psoas: 

• Obturator nerve:?It crosses the pelvic brim in front of the sacroiliac joint and then leaves the pelvis by passing into the thigh through the obturator foramen. 

• Fourth lumbar root of lumbosacral trunk:?It emerges from the medial border of the psoas at the pelvic brim. It takes part in the formation of sacral plexus. 

Branches leaving the anterior surface of psoas: 

Genitofemoral nerve:?After emerging from the anterior surface of the muscle, it runs down in front of it and divides into a genital branch and a femoral branch. The former supplies the cremaster muscle and the latter supplies a small area of skin of thigh. 

53. Round window (fenestra cochlea) of middle ear is closed by 

A. foot plate of stapes 

B. secondary tympanic membrane 

C. vestibular membrane 

D. foot plate of incus 

Ans b 

The round window is one of the two openings into the inner ear. It is closed off from the middle ear by the round window membrane, which vibrates with opposite phase to vibrations entering the inner ear through the oval window. It allows fluid in the cochlea to move, which in turn ensures that hair cells of the basilar membrane will be stimulated and that audition will occur. 

The secondary tympanic membrane (or round window membrane) covers the round window, sealing off one of two openings into the inner ear. It separates the scala tympani of the cochlea from the middle ear. It vibrates with opposite phase to vibrations entering the cochlea through the oval window as the fluid in the cochlea is displaced when pressed by the stapes at the oval window. This ensures that hair cells of the basilar membrane will be stimulated and that audition will occur. 

54. Portal vein formation lies 

A. behind the second part of duodenum 

B. posterior to the neck of the pancreas ,r 

C. posterior to the body of the pancreas 

D. posterior to the tail of the pancreas 

Ans b 

The pancreas, an exocrine and endocrine gland, has a head, neck, body, and tail. The portal vein is formed posterior to the neck of the pancreas by the union of the superior mesenteric and splenic veins. 

55. The knee joint is supported by all the following ligaments, EXCEPT 

A. Anterior cruciate ligament 

B. Inverted Y-shaped ligament of Bigelow 

C. Oblique popliteal ligament 

D. Fibular collateral ligament 

Ans B 

The iliofemoral ligament is a ligament of the hip joint which extends from the ilium to the femur in front of the joint. It is also referred to as the Y-ligament (see below) or the ligament of Bigelow, and any combinations of these names. 

With a tensile strength exceeding 350 kg (772 lbs),[1] the iliofemoral ligament is not only stronger than the two other ligaments of the hip joint, the ischiofemoral and the pubofemoral, but also the strongest ligament in the human body and as such is an important constraint to the hip joint 

56. Stimulation of J receptors causes all of the following EXCEPT 

A. Bradycardia 

B. Hypotension 

C. Hypertension 

D. Rapid breathing 

Ans C 

J-receptors (juxtacapillary) are nerves innervating into the body of the lung. They are present in the alveolar interstitium and are innervated by fibers of the vagus nerve.[1] J-receptors respond to events such as pulmonary edema, pulmonary emboli, pneumonia, congestive heart failure and barotrauma, which cause a decrease in oxygenation and thus lead to an increase in ventilation/respiration. They may be also stimulated by hyperinflation of the lung as well as intravenous or intracardiac administration of chemicals. 

The stimulation of the J-receptors causes a reflex increase in breathing rate, and is also thought to be involved in the sensation of dyspnea, the subjective sensation of difficulty breathing. [2][3] The reflex response that is produced is apnea followed by rapid breathing, bradycardia, and hypotension (pulmonary chemoreflex). The physiologic role of this reflex is uncertain, but it probably occurs in pathologic states such as pulmonary congestion or embolization.[4] These receptors were discovered by Dr. A.S Paintal 

57. The structures, outside the blood brain barrier are all the following, EXCEPT 

A. Neurohypophysis. 

B. Area postrema 

C. OVLT 

D. Locus ceruleus 

Ans D 

Circumventricular organs (CVOs) are structures in the brain that are characterized by their extensive vasculature and lack of a normal blood brain barrier (BBB).[1] The CVOs allow for the linkage between the central nervous system and peripheral blood flow; additionally they are an integral part of neuroendocrine function.[2] The lack of a blood brain barrier allows the CVOs to act as an alternative route for peptides and hormones in the neural tissue to the peripheral blood stream, while still protecting it from toxic substances.[3][4] CVOs can be classified in two ways, the sensory and the secretory organs. 

The sensory organs include the area postrema (AP), the subfornical organ (SFO) and the organum vasculosum of lamina terminalis (OVLT.) They have the ability to sense plasma molecules and then pass that information into other regions of the brain. Through this, they provide direct information to the autonomic nervous system from systemic circulation 

The secretory organs include the subcommissural organ (SCO), the posterior pituitary (also known as the neurohypophysis), the pineal gland, the median eminence and the intermediate lobe of the pituitary.[2] These organs are responsible for secreting hormones and glycoproteins into the peripheral vascular system using feedback from both the brain environment and external stimuli. 

All of the circumventricular organs, besides the SCO, contain extensive vasculature and fenestrated capillaries which leads to a ‘leaky’ BBB at the site of the organs. Furthermore, all CVOs contain neural tissue, allowing them to play a role in the neuroendocrine system. It is highly debated if the choroid plexus can be included as a CVO. It has a high concentration of fenestrated capillaries, but its lack of neural tissue and its primary role of producing cerebrospinal fluid (CSF) usually excludes the choroid plexus from the CVO classificatio 

The locus coeruleus (also spelled locus caeruleus) is a nucleus in the pons (part of the brainstem) involved with physiological responses to stress and panic 

The locus coeruleus is the principal site for brain synthesis of norepinephrine (noradrenaline). The locus coeruleus and the areas of the body affected by the norepinephrine it produces are described collectively as the locus coeruleus-noradrenergic system or LC-NA system.[3] Norepinephrine may also be released directly into the blood from the adrenal medulla. 

58. All are TRUE regarding erythropoietin, EXCEPT 

A. In adults about 80% of it comes from the kidneys and 15% from the liver. 

B. It 'is a glycoprotein with a molecular weight of about 34,000. 

C. Its function is to stimulate red cell production, and its formation in response to hypoxia. 

D. Its blood level is markedly decreased in anemia. 

Ans D 

EPO, is a glycoprotein hormone that controls erythropoiesis, or red blood cell production. It is a cytokine (protein signaling molecule) for erythrocyte (red blood cell) precursors in the bone marrow. Human EPO has a molecular weight of 34,000. 

Erythropoietin levels in blood are quite low in the absence of anemia, at around 10 mU/mL. However, in hypoxic stress, EPO production may increase a 1000-fold, reaching 10,000 mU/mL of blood. EPO is produced mainly by peritubular capillary lining cells of the renal cortex; which are highly specialized epithelial-like cells. It is synthesized by renal peritubular cells in adults, with a small amount being produced in the liver 

Regulation is believed to rely on a feed-back mechanism measuring blood oxygenation.[10] Constitutively synthesized transcription factors for EPO, known as hypoxia-inducible factors (HIFs), are hydroxylated and proteosomally digested in the presence of oxygen 

59. The major stimulus for receptive relaxation of the stomach is 

A. food in the stomach 

B. food in the intestine 

C. CCK 

D. secretin 

Ans A 

Vagovagal reflex refers to gastrointestinal tract reflex circuits where afferent and efferent fibers of the vagus nerve[2] coordinate responses to gut stimuli via the dorsal vagal complex in the brain. The vagovagal reflex controls contraction of the gastrointestinal muscle layers in response to distension of the tract by food. This reflex also allows for the accommodation of large amounts of food in the gastrointestinal tracts. 

The parasympathetic vagus nerve composed of both afferents and efferents carries signals from stretch receptors, osmoreceptors, and chemoreceptors to dorsal vagal complex where the signal may be further transmitted to autonomic centers in the medulla. Efferent fibers of the vagus then carry signals to the gastrointestinal tract up to 2/3 of the Tranverse Colon (coinciding with the second GI Watershed Point). 

[edit]Function 

The vagovagal reflex is active during the receptive relaxation of the stomach in response to swallowing of food (prior to it reaching the stomach). 

When food enters the stomach a "vagovagal" reflex goes from the stomach to the brain, and then back again to the stomach causing active relaxation of the smooth muscle in the stomach wall. 

If vagal innervation is interrupted then intra-gastric pressure increases. 

The vagal afferents are activated during the gastric phase of digestion when the corpus and fundus of the stomach are distended secondary to the entry of a food bolus. The stimulation of the mechanical receptors located in the gastric mucosa stimulates the vagus afferents. The completion of the reflex circuit by vagus efferents leads to the stimulation of postganglionic muscarinic nerves. These nerves release acetylcholine to stimulate two end effects. One, the parietal cells in the body of the stomach are stimulated to release H+. Two, the ECL cells of the lamina propria of the body of the stomach are stimulated to release histamine. Vagal stimulation of the peptidergic neurons, occurring simultaneously, leads to the release of gastrin-releasing-peptide. Finally, the Delta cells are inhibited to reduce the inhibition of gastrin release. 

60. Deuterium oxide is used to measure the volume of 

A. extracellular fluid 

B intracellular fluid 

C plasma 

D total body water 

Ans D 

Total body water (body composition) has been measured using stable isotopes of oxygen (oxygen-18) and deuterium (deuterium oxide, D2O) for more than 40 years. The principle is based on the theory that water is distributed in all parts of the body except body fat. Most researchers chose deuterium oxide to estimate total body water due to the lower cost of isotope. The 4% overestimation of total body water by the technique can be corrected in the final calculations.