Correct Answer - A
Ans: A. There is extremely forceful peristaltic activity leading to
episodes of chest pain and dysphagia

NutCracker Oesophagus is a hypermotility disorder with high
amplitude peristalsis. It is a condition in which extremely forceful peristaltic activity leads to episodic chest pain and dysphagia.
Treatment is with nitrates or nifedipine.
Ref. davidsons principles and practice 23rd edition page no.795

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Correct Answer - A
The answer is A (Increased amplitude of QRS complex):

Athletic Heart Syndrome
Athletic Heart Syndrome is a benign condition consisting of
physiologic adaptations to the increased cardiac workload of
exercise in trained athletes.

It represents a constellation of clinical findings that are the result of normal physiologic adaptation to strenuous physical activity.

In response to the increased physical demand, the left ventricles
dilate and wall thickness increases.

The mass to volume ratio,
however, does not change.

Physical examination
Decreased body fat and increased muscle mass (generally very
physically fit)

Pulse slow and often irregular (sinus bradycardia or bradycardia with first-and second-degree blocks)

Grade I or II mid-systolic murmurs (benign functional ejection
murmur resolves with Valsalva maneuver)

Third and fourth heart sounds very common (benign filling sounds)

Blood pressure typically remains normal

Electrocardiogram rhythm
Rhythm
- Sinus bradycardia of 40 to 55 beats /min while at rest- Sinus pauses of more than 2.0 seconds due to increased vagal
tone

- Wandering atrial pacemaker found only in dynamic athletes
- First degree atrioventricular block present only at rest; P-R interval
normalizes with exercise
- Second degree atrioventricular block present only at rest: Mobitz I
(wenckebach block) common in marathon runners; Mobitz II rare in
athlete's heart.
Voltage: QRS voltage (Amplitude)
- Left ventricular hypertrophy found in 85% of Olympic marathon
runners
- Right ventricular hypertrophy common in dynamic athletes but
rarely seen in sedentary controls and static athletes sedentary
control and static athletes
Repolarization
- S-T segment elevation with peaked T waves normalizes with
exertion
- S-T segment depression may be rarely found in athletes
T-wave inversion in lateral leads associated with interventricular
septal hypertrophy in static athletes (can be a normal finding in
dynamic athletes)

Chest radiography
- The heart is globular in appearance, particularly in endurance athletes.
- Cardiomegaly (cardiothoracic ratio >0.50)

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Correct Answer - C
Answer: C - High dose vasopressin

Vasopressin is an alternative vasopressor at high doses, causes
vasoconstriction by directly stimulating smooth muscle V1
receptors.

American Heart Association (AHA) guidelines states “Vasopressin is
a reasonable first-line vasopressor in patients with ventricular
fibrillation or pulseless ventricular tachycardia. Additionally, the
guidelines comment that one dose of vasopressin 40 U may replace
the first or second dose of epinephrine in all pulseless sudden
cardiac arrest scenarios, including asystole and pulseless electrical
activity

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Correct Answer - A
Ans. is 'a' i.e., Hypotension

Hypotension is the most common acute complication of
hemodialysis particularly among patients with diabetes mellitus.

Factors involved are :-
Excessive ultrafiltration, with inadequate compensatory vascular
filling, impaired vasoactive or autonomic response, osmolar shifts, overzealous use of antihypertensives

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Correct Answer - B
Ans. is 'b' i.e., Middle cerebral artery

Hemiplegia most commonly occurs due to lesion of middle cerebral
artery

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Ecg pocketcard
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Correct Answer - B
Ans. is 'b' i.e., Ceftazidime

Adverse effects of cephalosporins

1.Hypersensitivity reaction - It is the most usual side effect. There is
cross allergy between penicillins and cephalosporine in 5-10% of
cases.
2.Diarrhea - due to alteration of gut flora, maximum with oral
cephradine and parentral cefperazone (cefperazone is significantly excreted in bile) → May cause pseudomembranous colitis caused by Cl. difficle.
Superinfection - Most common organisms are candida and
pseudomonas, less common are staphylococci, proteus.

Ceftriaxone achieves high concentration in bile and, as the calcium salt, may precipitate to cause symptoms resembling cholelithiasis
(Biliary pseudolithiasis).
3.Nephrotoxicity - highest with cephaloridine.
4.Bleeding - ceftriaxone, cefoperazone, moxalactam & cefamandole can cause hypoprothrmbinemia and bleeding.
Disulfiram like reaction - cefamandole, cefoperazone, moxalactam and cefotetan can cause disulfiram like reaction with alcohol.
5.Neutropenia and thrombocytopenia can be caused by ceftazidim.


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Correct Answer - A
Ans: A. Low TSH with more t3 or t4

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Correct Answer - C
Answer is C (Propranolol)
The symptoms of the patient and echocardiographic finding of
asymmetrical septal hypertrophy almost confirms the diagnosis of
Hypertrophic cardiomyopathy. Beta Blockers should be the initial
drug Q in symptomatic individuals
Management of HOCM
Avoidance of strenuous physical activity

Beta Blockers should be the initial drug Q in symptomatic individuals.
They reduce:
- Heart rate
- Blood pressureStiffness of left ventricle
- Fatal arrythmias

Calcium channel BlockersQ (verapamil and diltiazem) are alternative
drugs.
- They reduce-stiffness of ventricle
- Elevated diastolic pressures

Amiadarone may be used to reduce arrythmias.
Surgical myomectomy

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Correct Answer - D
Answer- D. M component is IgA in 25% of the patients The immunoglobulins move heterogeneously in an electric field and form a broad peak in the gamma region.

The y globulin region of the electrophoretic pattern is usually increased in the sera of patients with plasma cell tumors.

There is a sharp spike in this region called M component (M for monoclonal).

The serum M component in multiple myeloma will be IgG in 53% of patients, IgA in 25%, and IgD in 1%; 20% ofMietits will have only
light chains in serum and urine.


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Correct Answer - C
Answer- C. Urinary calculi

Urinary calculi (oxalate stones in ileal disease), local extension of
Crohn disease involving ureter or bladder, amyloidosis, drug-related
nephrotoxicity

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