ACROSS

A complete Review of Short Subjects

Volume Skin Anaesthesia
Radiotherapy Nuclear Medicine

1 Radiodiagnosis
Ophthalmology
Psychiatry
Orthopaedics

Eighth Edition

Authored by

Saumya Shukla DNB Radiodiagnosis

Assistant Professor
Nizam's Institute of Medical Sciences
Hyderabad, India

Anurag Shukla MS MCh (Orth), UK

Edited and Proofread by
Monika Shukla
Vibha Shukla

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A Complete Review of Short Subjects (Vol-1)

Eighth Edition: 2014

ISBN : 978-93-5152-345-1

Printed at
Not only this book, my whole life is dedicated to
Bhagwan Ratneshwar, my Mother and Father
 Preface to the Eighth Edition
We are thankful for your reviews that has given us a fresh impetus to completely change this book in a more systematic way.
In this edition, the entire book has been revised, with a view to eliminating errors, incorporating suggestion of readers,
updating concepts and discarding material that is no longer relevant. Our aim was to update all subjects according to recent
available text. For convenient reading subject has been divided into theory and MCQ portion and further subdivided into
chapters and sub-chapters; according to their topics. In this way the book has been kept concise while remaining as up to date
and accurate as possible. Our major goal was to make this book more interesting and user-friendly, with a substantial reduction
in overall size of the subject. To achieve this goal the book has been rigorously edited involving their amalgamation, division,
or deletion. This has been put to effect without loss of crucial information but with gain in conciseness and clarity. We have kept
the book succinct and to the point. The job that was no mean feat has become possible only because of the best endeavours of
our team.
Many MBBS students do not have a good background in these subjects. This examination-oriented book is written with
these students in mind. The language is simple, explanations clear and presentation very systematic. Our commitment to
simplicity is total! This book will help you overcome the fear of these subjects. Topics, which usually confuse the students,
are explained in greater detail. This text will help you learn faster and enjoy it more! Stress is on understanding as well as
memorization. It is intended that every topic should be approached in a pragmatic and flexible manner.
This book is an important text for Postgraduate Entrance Exams. Your choice of a book can mean success or failure. Because
today you need a book, that can help you streak ahead of competition and succeed. No one knows more about your needs than
us. It is a tall claim, but it is true!

Phenomenon of Contradiction (POC)

I think the time has come to make you realize the importance of the phenomenon of contradiction (POC) in medical preparatory
exams. You all must understand, that medical science is a dynamic (ever changing) and relative science which is made-up of
innumerable number of research papers from different part of world (some of them contradicting each other and with their
own most common, most preferred and best, etc). And each topic has been explained in books of various specialties (like a topic
about kidney is explained in books of nephrology, urology, radiodiagnosis, genitourinary imaging, nuclear medicine, oncology,
radiotherapy, medicine, surgery, anatomy, physiology and so on) giving their own shades to the topic focusing more on their
aspect of that topic; and not to mention about numerous authors of each subject.
So when a book by an author (many times even Harrison) says anything, it is not always an absolute truth, if it is against
the basic broad concept of that topic. So be very cautious before blatantly remarking any answer wrong on the basis of single
line written in one book. And try to avoid amending answers on the basis, of one British/American/French research paper until
and unless it is a ground breaking/Nobel prized research paper because most of the times you even do not know the statistical
significance of that paper.
Your standard reference/textbooks tell you the extract of statistically significant research papers (most of which are paid
review papers comparing the contradictory papers about that topic and few new statistically significant research papers). So
leave this cumbersome responsibility of which paper to include/believe or exclude/not to believe on reference books.
In nut shell, never try to believe an answer on the basis of journals (freely available on internet) when you are getting a
logical answer in your reference textbooks. Because most of the PGMEE questions are concept (not research) based.
We have elaborately explained this phenomenon in few selected answers, which were controversial/wrong according to
some reviews. In last 12 years (initial 6 years in CROSS) we have explained few of these questions at least 6 times but the answer
always remained same. It is not always possible to elaborate all answers to such a huge extent but believe us research done to
find a perfect fitting answer is always far more extensive and exhaustive and many times include reading hundreds of pages
and spending weeks of time for getting one perfect line.

Knowledge with Purpose: Why, How, What Algorithm

Knowledge without purpose is only a useless collection of words. So before attempting any question, always follow the
algorithm of why, how, and what, i.e. why this question has been asked?, how it is going to make me a better clinician? and
 Preface to the Eighth Edition

what have I learnt while finding the correct answer? After following this approach you would realize that most questions are
based on very basic concepts of medical science used to differentiate various diseases. And this process of giving purpose to
your learning would never allow you to forget the concept, making your remembering easy.
Never restrict your imagination by thinking that only purpose of reading is to pass PGMEE. Instead, always think that how
this information makes me a better, safer clinician. Believe me, a student who approaches the exams in this way always gets
success, whatever the pattern of examination maybe because purpose of all examinations is only and only this.
This book has helped students to secure good ranks in various patterns of entrance exams including AI, AIIMS, PGI, DNB,
JIPMER, CMC, AFMC, AMU and various state PGME exams for last 14 years. So, do not worry about the pattern of NEET and
its conducting body (presently DNB) because this book incorporates the latest text and 20 year questions about most important
topics in a sequential manner.

May 21, 2014 Dr Anurag Shukla

Dr Saumya Shukla
Dr Siddharth Dixit
Dr Khushi Shukla

Preface to the First Edition

"Try to achieve what you like, otherwise you have to like what you achieved".
Friends, have you ever given your few valuable minutes to think about the reasons of being successful (or unsuccessful) in
PGMEE.
What I feel, that this success is an art which not only requires a lot of grey matter but also needs an intense will to succeed,
a lot of devotion, a positive attitude and above all a firm determined constant effort in right direction with proper strategy.
Now question arises that what is the proper strategy?
And in most simple words "The only part of your knowledge, which is retained between your two ears, is going to help
you in your exams."
- So do not waste your very precious time in reading worthless incomprehensible unretainable guides or books.
- Be to the point in remembering things.
- Let your confusions clear by repeated revisions, before exams.
- Reading how many times is more important than reading how much?
- Knowing few things about every topic and everything about few topics is important aspect of your preparation.
I have kept all these things in my mind while writing this book. This book provides at least three to four times revision of
almost each and every important topic in a single reading. And with every repetition the topic gets more concise and more
lucid.
I have worked a lot, to make this book easily retainable, which you will realize as you proceed further with the book.
In this book there is collection of 21 years solved papers of AI, AIIMS and PGI PGMEE. All answers have been referenced
from the most recent and standard textbooks available. Relevant questions of JIPMER, AMU, Kerala, UP, Tamil Nadu, Karnataka,
MP, West Bengal, Rohtak, CMC Vellore, Delhi, Rajasthan, Bihar, Jharkhand, MAHE are also solved.
Kindly let me know your opinion and send me your invaluable suggestions to further improve this book and make it more
readable and enjoyable.
I know you are going to fight in the toughest of battleground!
Best of luck.

Saumya Shukla

v
 Acknowledgments
"To Bhagvan Ratneshwar"

At the very outset, I fail to find adequate words, with limited vocabulary at my command, to express my emotions to 'Dear God',
whose eternal blessings, divine presence, and masterly guidance helps us to fulfill all our goals.
It is very difficult to find a true Guru in this materialistic world. But I am lucky and I fail to find words to express my
emotions to "Swami Swayambodhanand Sarawasati" (Swami Ji) for his colossal and beatific spiritual cosseting, without which
I would never have been like this.
I will always remain obliged and grateful to my teachers Prof OP Singh, MS, FICS, MAMS; Prof VD Sharma, MS,
FICS, Prof Vineet Sharma, MS, FICS, Dr Ashish Mahendra, MS, MCh, FRCS, Orthopaedics Department, KGMC, Lucknow,
Prof KD Khare Retd HOD, AFMC, Pune and Dr RK Singh, MS, D Orth for their inspiration and encouragement, which gave
succour and strength to my thoughts and mapped my way to find a modus operandi for myself.
Sometimes it is not easy to express your emotions in words especially when you have to say thanks to your parents for
their constant undemanding love, dedication, sacrifice, inspiring guidance, affectionate encouragement and never ending
enthusiasm; without which this book would not have seen the light of the day.
An ostentatious use of word will not be sufficient to express my heartiest thanks to Dr SK Dikshit, Mr LN Dikshit,
Dr (Mrs) Arti Shukla (MD, Obs and Gynae), Dr Smita (RIMS) and Dr Sneha Dikshit (AMU), Dr Harish Dikshit, Dr VN Shukla,
Dr Shraddha Shukla, Smt Kamla Devi, Mr PS Shukla and Mr Dev S Shukla, Mr Sujit Kumar Mishra, Aditi and Kriti Tripathi
for their meticulous efforts during the making of this book. Their valuable and critical suggestions, constant inspiration and
encouragement, instinctive corrective measures, tireless efforts, unstinted cooperation and sentimental support throughout
have made this marathan task a smooth journey.
It is hard to envisage how it could have happened without the assiduously deligent and ingenious editing effort and proof
reading of Dr Monika, Mrs Vibha Shukla, Mr VS Shukla. And infact this book would never have been like this without the expert
technical consultations and dexterous work of Mr Sayeed and Mr Saleem and their team at Compsphere.
It would be a sacrilege if I do not mention the names of my friends, whom I always find with me in every filed of life.
- Dr Sunil Kumar Paltan (Asst Prof Ortho, Safai) - Dr Gopal Singh, MS Ortho, KGMC
- Dr Sachin Awasthi, MS Ortho, KGMC - Dr Pradeep Pandey, MS Ortho, KGMC
- Dr Saurabh Agarwal, MS Ortho, KGMC - Dr Rudra Pratap Singh, SR Orthopaedics, GTB, Delhi
- Dr Mukul Singh, MD Ortho, KGMC - Dr Atul Jain, MS Orthopaedics, KGMC
- Dr Harish Ghoota, MS Orthopaedics, KGMC - Dr Shaleen Verma, MS Orthopaedics, KGMC
- Dr Ankur Das, MS Orthopaedics, KGMC - Dr Abhishek Manu
- Dr Nitin Joshi, MS ENT, KGMC - Dr Sandeep Buratodi, MD Radiology, KGMC
- Dr Sandeep Tripathi, MD Pediatrics, LHMC, New Delhi - Dr Sandeep Rai, MS Gen Surgery, GSVM
- Dr Suneel Chamoli, MD Psychiatry, KGMC - Dr Ashish Gupta, MD Radiology, KGMC
- Dr Sharad Chandra, DM Cardiology, AIIMS - Dr Vipin Gupta, MS Gen. Surgery
- Dr Anil Kumar Singh, MD, Medicine MAMC, New Delhi - Dr Nasir Ahmed, BRDMC, Gorakhpur
- Dr Jai Jag Tambe, SR, Pediatrics, LHMC, New Delhi - Dr Gunjan Das Agarwal, MD Radiology, KGMC
- Dr Chitwan Dubey, MS Obs and Gyne, Grants, Mumbai - Dr Anubhav Pandey, MD Microbiology, AIIMS
- Dr Ambuj, MS General Surgery (Pune) - Dr Sandhya Mishra, DNB, Obs and Gynae, Mumbai
- Dr Chander Shekher Kumar, MS, Ophtha, AIIMS - Dr Vikas Mathur, NRSMC
- Dr Parul Kakkar, Dr Gaurav Mittal - Dr Arijit Mitra, NRSMC
- Dr Rohit Jain, MD Patho, Ahmedabad - Dr Gunjan Raghuvanshi, MD Patho, Agra
- Dr Vineet Kumar, MD Psychiatry, PGI Chandigarh - Dr Nilanjana Gosh
- Dr Prajna Latika - Dr Avneet, KGMC, Dr Gopal Singh, GSVM
- Dr Anurag Yadav, MD Pediatrics - Dr Athar Mohammad, KGMC
 Acknowledgments

- Dr Shobhna Singh, KGMC, Lucknow - Mr Ananad Singh

- Mr Rajpal Singh - Mr Rajan Singh
- Mr Inder Mohan, Mr Sumit Solanki - Mr Pranav, Mr Ravi
When it comes to expressing the emotions, I feel hopelessly inarticulate to Dr Abu Hatim A. Rashid, MS, SKIMS, MCh
Pediatrics Surgery KGMC, Dr Sheeba Sarvat, Dr Shafat MD, Pediatrics, SKIMS, Srinagar (JandK) and Dr Mozzam Jah, Dr O. P.
Gupta, MS Ortho, Dr Arif Kamal MS Ortho, Dr Arvind Kumar, KGMC, for their excellent constructive evaluation, humour at
the time of depression and assistance at each and every step of our work.
We are greatly indebted to many individuals who helped with the preparation of this book. And we would like to express
our gratitude to those who were especially helpful- Dr Mudit Khanna, MS Ortho, Dr Sandeep Buratodi, SR Radiodiagnosis Sri
Chitra Institute, Dr Athar SR Oncology KGMC, Dr Javed MS Optha., Dr Parthiv Desai, DM Neurology, KGMC, Dr Devangi
Desai, Dr Mohit Dhingra MS Ortho, Dr Vandana Dhingra MD, Nuclear Medicine, Dr Atul Dhawan MS Ophtha, Dr Gaurav
Anand Mishra, MS Ophtha., Dr Pallavai Chaudhary MS Ophtha. and Dr Deepak Chaudhary (ELMC).
It gives me great pleasure to thank Dr Farzana Mahdi (Director Academics), Prof Jayant Bajpai, Prof RP Agarwal, Dr
Shakeel A Quidwai and Dr MP Singh (Associate Professor), Dr AN Mishra, Dr Sohail Ahmad and Dr Farid Mohammad
(Assistant Professor), Dr Sanjeev Kumar, Dr Amir Khan, Dr Firoz Ahmad, Dr Rakshit, Dr Yasir Ali Khan, Dr Fahad-ul-Islam,
Dr Mayank Chauhan, Dr Sudheer Rajauria and Dr Deepak Chaudhary (Orthopaedic Resident, EMLC and Hospital, Lucknow),
without whose support and constructive suggestions this edition could hardly have been undertaken.
We thank Shri Jitendar P Vij (Group Chairman) and Mr Bhupesh Arora (Associate Director Sales and Marketing M/s
Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India for their thoroughly professional approach. Their constant interest
and input have had a significant impact on the final structure of this book. It has been a pleasure to work with an individual
who constantly offered wise and superb skilled suggestions. And at last but not the least, I am thankful to Mr. Inder Mohan,
Mr Sumit Solanki, Mr Pranav, Mr Rajkumar, Mr Shadab, Mr Manish and Mr Ravi Sharma for their extremely diligent efforts.
We are grateful to the readers of the previous edition. Suggestions from students around the country have been most
helpful in the formulation of this edition. We look forward to receiving similar input in the future. We hope that anyone with an
idea, suggestion, or criticism regarding this book will feel free to contact us.
Such comments are always welcome and I solicit additional corrections and criticism, which maybe addressed to us at-
dr_anurag_ortho@yahoo.co.in, dr_saumyadikshit@yahoo.com, siddharth_dikshit@yahoo.com.

From the Publishers Desk

We request all the readers to provide us their valuable suggestions/errors (if any)
at: jaypeemcqproduction@gmail.com
so as to help us in further improvement of this book in the subsequent edition.

vii
 Contents
I. Dermatology (Skin and Veneral Diseases) S.1-S.200
1. General Anatomy and Appendageal Disorders 3
2. Disorders of Pigmentation 23
3. Allergic Disorders and Dermatitis (Eczema) 35
4. Papulosquamous Disorders 48
5. Papulo-Vesicular/Vesico-Bullous Disorder and Immunologically Mediated Disease 65
6. Systemic Disease with Prominent Cutaneous Features, Photosensitivity and Cutaneous Drug Erruptions 92
7. Leprosy (Hensen's Disease) 118
8. Skin Tuberculosis and Other Bacterial Infections 132
9. Fungal Infections 141
10. Scabies 151
11. Pediculosis 156
12. Veneral (Sexually Transmitted) Disease 157
13. Genodermatoses and Deficiency Diseases 177
14. Malignant Skin Disease 190

II. Anaesthesia A.201-A.376

1. Anaesthesia Trolly, Instruments, Circuits, Ventilation and Preanaesthetic Medication 203
2. Neuromuscular Blockers 246
3. Intravenous Anaesthetics 263
4. Inhalational Anaesthetics 283
5. Clinical Anaesthesia 301
6. Anaesthetic Complication and Management 323
7. Local Anaesthetics and Blocks 342
8. Spinal, Epidural and Caudal Anaesthesia 358

III. Radiotherapy RT.377-RT.418

1. Photon and Photon Interactions 379
2. External Beam Radiation/Teletherapy 383
3. Brachy-Therapy 384
4. Radioisotopes 386
5. Radiosensitivity 387
6. Radioprotection and Sensitization 388
7. Conformal Therapy and IMRT 389
8. Stereotactic Radiotherapy (SRT) 390
9. Craniospinal Irradiation 391
10. Biological Effect of RT and Whole-Body Irradiation Syndromes 391
Questions 395
Explanations 402

IV. Nuclear Medicine NM.419-NM.436

Theory 421
Questions 429
Explanations 431
 Contents

V. Radiodiagnosis RD.437-RD.616
1. Physics and Technique 439
2. Systemic Radiodiagnosis I: Neurology and Nephrology 456
3. Systemic Radiology II: Others 502
4. Diagnostic Features and Specific Signs 579
5. Investigation of Choice 597

VI. Psychiatry P.617-P.840

1. Signs and Symptoms in Psychiatry 619
2. Psychoanalysis, Ego and Defense Mechanisms 642
3. Cognitive Disorders 664
4. Substance Related Disorders 688
5. Schizophrenia 707
6. Other Psychotic Disorders/Delusional Disorder 724
7. Mood Disorders 732
8. Grief 757
9. Anxiety Disorders 758
10. Adjustment Disorder 776
11. Somatoform Disorder 777
12. Sexual Disorders 786
13. Gender Identity Disorder 787
14. Eating Disorders 788
15. Normal Sleep and Sleep Disorders 791
16. Impulse Control Disorders (Oniomania/Pyromania) 797
17. Personality Disorder 798
18. Paediatric Psychiatry 806
19. Drugs and Side Effects 819
20. Electroconvulsive Therapy 834

VII. Ophthalmology OP.841-OP.1160

1. Anatomy and Development of the Eye 843
2. Clinical Presentation and Methods in Ophthalmology 847
3. Basic Principles of Ocular Therapy 857
4. Optics and Refraction 859
5. Diseases of the Conjunctiva 878
6. Diseases of the Cornea 893
7. Diseases of the Sclera 919
8. Diseases of the Uveal Tract and Vitreous 921
9. Diseases of the Retina 941
10. Diseases of the Lens 990
11. Glaucoma 1020
12. Diseases of the Optic Nerve 1050
13. Tumours of the Eye 1063
14. Ocular Injuries 1089
15. Neuro-Ophthalmogy 1098
16. Strabismus and Nystagmus 1118
17. Diseases of the Lid 1138
18. Diseases of the Lacrimal Apparatus 1146
19. Community Ophthalmology 1151

ix
 A Complete Review of Short Subjects (Vol-1)

VIII. Orthopaedics OR.1161 - OR.1488

Traumatology
1. Bone Histology 1163
2. Polytrauma 1174
Injuries of Upper Limb
3.1 Shoulder Dislocation and Subluxation 1182
3.2 Fracture Around Shoulder Arm 1192
3.3 Injuries Around Elbow 1197
3.4 Forearm Injuries 1214
3.5 Fracture Lower End Radius/Wrist 1217
3.6 Carpal Injuries 1222
3.7 Hand Injuries 1225
Injuries of Lower Limb
4.1 Fracture of Pelvis and Acetabulum 1229
4.2 Fractures Around Hip 1233
4.3 Dislocation of Hip 1245
4.4 Examination of Hip 1250
4.5 Fracture Subtrochanteric and Shaft Femur 1253
4.6 Fracture Patella and Both Bones Leg 1259
4.7 Ankle and Foot Injuries 1262
5. Spinal Injuries 1268
6. Sports Injury/Ligamentous Injury 1289
7. Advanced Orthopaedics and Managements 1304
8. Nerve Injuries 1317
Paediatric Orthopaedics
9. Fractures in Children 1337
10. Paediatric Limb Anomaly 1342
11. Paediatric Hip Problem 1344
12. Paediatric Knee and Foot Problem 1356
13. CTEV 1363
14. Paediatric Spinal Problem 1368
15. Genetic and Developmental Disorders of Bones 1372
16. Metabolic Bone Diseases 1381
17. Avascular Necrosis of Bone and Osteochondritis 1401
18. Arthritis 1406
19. Regional Pain Syndrome 1436
20. Infective Bone Diseases 1447
21. Bone Tumors 1457